Provider Demographics
NPI:1083393490
Name:BOSTIC, SEAN LAWRENCE
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:LAWRENCE
Last Name:BOSTIC
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 1:415 GLENSPRINGS DR STE 301
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2354
Mailing Address - Country:US
Mailing Address - Phone:513-570-4068
Mailing Address - Fax:513-672-1028
Practice Address - Street 1:415 GLENSPRINGS DR STE 301
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-2354
Practice Address - Country:US
Practice Address - Phone:513-570-4068
Practice Address - Fax:513-672-1028
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker