Provider Demographics
NPI:1568222479
Name:BOSLEY, BRITTANY N
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:N
Last Name:BOSLEY
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 1:502 S MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4884
Mailing Address - Country:US
Mailing Address - Phone:309-820-7616
Mailing Address - Fax:
Practice Address - Street 1:502 S MORRIS AVE # 304
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4884
Practice Address - Country:US
Practice Address - Phone:309-820-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health