Provider Demographics
NPI:1396384368
Name:BOSWELL, NICHOLAS PAUL (DPT, PT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1344
Practice Address - Country:US
Practice Address - Phone:803-536-5509
Practice Address - Fax:803-536-4104
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225100000X
GAPT014428225100000X
TN15372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist