Provider Demographics
NPI:1376749598
Name:BOSWELL, THERESA T (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:T
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 HOWE AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1073
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:916-550-5003
Practice Address - Street 1:1908 N BEALE RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6937
Practice Address - Country:US
Practice Address - Phone:530-743-6888
Practice Address - Fax:530-743-9823
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7261 1231041C0700X
CA764051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40967800Medicaid