Provider Demographics
NPI:1518007806
Name:BOSTIC, LEIGH
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:BOSTIC
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 1:110 MANLY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3025
Mailing Address - Country:US
Mailing Address - Phone:864-298-8026
Mailing Address - Fax:864-298-8032
Practice Address - Street 1:110 MANLY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3025
Practice Address - Country:US
Practice Address - Phone:864-298-8026
Practice Address - Fax:864-298-8032
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC54591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1013Medicaid
SCQ49921E638OtherMEDICARE PTAN