Provider Demographics
NPI:1689765232
Name:BOSL, DIANE (MS LP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BOSL
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 2ND STREET SOUTH
Mailing Address - Street 2:SUITE 180 GRANITE CITY COUNSELING, LLC
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387
Mailing Address - Country:US
Mailing Address - Phone:320-257-1800
Mailing Address - Fax:320-257-1801
Practice Address - Street 1:818 2ND ST S
Practice Address - Street 2:SUITE 180
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-4528
Practice Address - Country:US
Practice Address - Phone:320-257-1800
Practice Address - Fax:320-257-1801
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2823103T00000X
MN7148104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN928250500Medicaid