Provider Demographics
NPI:1013565514
Name:BOSEMAN, TERRANCE C
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:C
Last Name:BOSEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6358 AQUILA WAY
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-7614
Mailing Address - Country:US
Mailing Address - Phone:202-207-6037
Mailing Address - Fax:
Practice Address - Street 1:6358 AQUILA WAY
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:91752-7614
Practice Address - Country:US
Practice Address - Phone:202-207-6037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty