Provider Demographics
NPI:1144564584
Name:BOSLEY, TERESA LYNN (OT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:BOSLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 ARDMORE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4924
Mailing Address - Country:US
Mailing Address - Phone:616-559-1054
Mailing Address - Fax:616-559-1056
Practice Address - Street 1:2505 ARDMORE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4924
Practice Address - Country:US
Practice Address - Phone:616-559-1054
Practice Address - Fax:616-559-1056
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006103225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist