Provider Demographics
NPI:1609247675
Name:BOOSALIS, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BOOSALIS
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 1:16855 PATTERSON DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-2603
Mailing Address - Country:US
Mailing Address - Phone:402-210-3111
Mailing Address - Fax:
Practice Address - Street 1:16855 PATTERSON DR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-2603
Practice Address - Country:US
Practice Address - Phone:402-210-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1903235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist