Provider Demographics
NPI:1700417193
Name:BOSTROM, CAROLINE ROSE SOMERVILLE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ROSE SOMERVILLE
Last Name:BOSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:
Other - Last Name:SOMERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-373-7116
Practice Address - Street 1:326 NEW SHACKLE ISLAND RD STE 300
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2494
Practice Address - Country:US
Practice Address - Phone:615-448-0517
Practice Address - Fax:615-448-0518
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist