Provider Demographics
NPI:1235686775
Name:BOSCH, LAURA JACLYN (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JACLYN
Last Name:BOSCH
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:PO BOX 1451
Mailing Address - Street 2:
Mailing Address - City:EL GRANADA
Mailing Address - State:CA
Mailing Address - Zip Code:94018-1451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 OLD BAYSHORE HWY
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-1602
Practice Address - Country:US
Practice Address - Phone:650-638-9142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291963225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist