Provider Demographics
NPI:1407173594
Name:BOSWORTH, MARILYN EATON (MS, CCC)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:EATON
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ALSACE CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2950
Mailing Address - Country:US
Mailing Address - Phone:904-273-8266
Mailing Address - Fax:
Practice Address - Street 1:105 ALSACE CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2950
Practice Address - Country:US
Practice Address - Phone:904-273-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3699891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist