Provider Demographics
NPI:1679218127
Name:BOSTIC, WILBERT JR
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:
Last Name:BOSTIC
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 W RUNNING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-1741
Mailing Address - Country:US
Mailing Address - Phone:410-313-6893
Mailing Address - Fax:
Practice Address - Street 1:5215 W RUNNING BROOK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-1741
Practice Address - Country:US
Practice Address - Phone:443-956-0154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant