Provider Demographics
NPI:1508344458
Name:BOSWORTH, REBECCA ANNE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44150 CROOKS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:AHWAHNEE
Mailing Address - State:CA
Mailing Address - Zip Code:93601-9748
Mailing Address - Country:US
Mailing Address - Phone:559-760-1200
Mailing Address - Fax:
Practice Address - Street 1:44150 CROOKS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:AHWAHNEE
Practice Address - State:CA
Practice Address - Zip Code:93601-9748
Practice Address - Country:US
Practice Address - Phone:559-760-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW83417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-1122279Medicaid