Provider Demographics
NPI:1295359222
Name:BOSWORTH, MISTY DAWN (BSW)
Entity Type:Individual
Prefix:MR
First Name:MISTY
Middle Name:DAWN
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3867
Mailing Address - Country:US
Mailing Address - Phone:765-662-9971
Mailing Address - Fax:
Practice Address - Street 1:101 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3867
Practice Address - Country:US
Practice Address - Phone:765-662-9971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100125240AMedicaid