Provider Demographics
NPI:1538673892
Name:BOSTROM, LUCIA
Entity Type:Individual
Prefix:
First Name:LUCIA
Middle Name:
Last Name:BOSTROM
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 1:20 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-2075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-2075
Practice Address - Country:US
Practice Address - Phone:781-302-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-24
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst