Provider Demographics
NPI:1033138813
Name:BOSWORTH, MARI JANE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARI
Middle Name:JANE
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N CHRISMAN AVE
Mailing Address - Street 2:SUTIE C
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2107
Mailing Address - Country:US
Mailing Address - Phone:662-843-3004
Mailing Address - Fax:662-843-0820
Practice Address - Street 1:712 N CHRISMAN AVE
Practice Address - Street 2:SUTIE C
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2107
Practice Address - Country:US
Practice Address - Phone:662-843-3004
Practice Address - Fax:662-843-0820
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117948Medicaid
MS65000060Medicare ID - Type UnspecifiedPROVIDER NUMBER