Provider Demographics
NPI:1033870696
Name:BOSAK, ELLIOTT JAMES
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:JAMES
Last Name:BOSAK
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 1:427 WEST TRAVELERS TRAIL, BURNSVILLE MN, 55337
Mailing Address - Street 2:427 WEST TRAVELERS TRAIL, BURNSVILLE MN, 55337
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-247-2954
Mailing Address - Fax:
Practice Address - Street 1:427 WEST TRAVELERS TRAIL, BURNSVILLE MN, 55337
Practice Address - Street 2:427 WEST TRAVELERS TRAIL, BURNSVILLE MN, 55337
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-247-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health