Provider Demographics
NPI:1164986402
Name:BOSH, KIMBERLY (LSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOSH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 MYSTIC DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-5313
Mailing Address - Country:US
Mailing Address - Phone:630-301-9995
Mailing Address - Fax:
Practice Address - Street 1:212 BARNEY DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5272
Practice Address - Country:US
Practice Address - Phone:815-927-5465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150103054104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker