Provider Demographics
NPI:1275849762
Name:BOSWELL, BETHANY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6524 SAINT MORITZ AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-2428
Mailing Address - Country:US
Mailing Address - Phone:214-364-0225
Mailing Address - Fax:
Practice Address - Street 1:930 W CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5823
Practice Address - Country:US
Practice Address - Phone:972-303-7021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX349892355S0801X
TX107967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX456606Medicare UPIN
TX676535Medicare UPIN