Provider Demographics
NPI:1003138710
Name:BOSLEY, TREBOR WELLINGTON (LPC)
Entity Type:Individual
Prefix:
First Name:TREBOR
Middle Name:WELLINGTON
Last Name:BOSLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:TREBOR
Other - Middle Name:WELLINGTON
Other - Last Name:BOSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHR
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 101YM0800X
ARP2010088101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK101YM0800XMedicaid