Provider Demographics
NPI:1710334297
Name:BOSTIC, KATHLEEN (PT,DPT,MOT,OTR/L)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:PT,DPT,MOT,OTR/L
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MALARCHIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2164 NISQUALLY ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5687
Mailing Address - Country:US
Mailing Address - Phone:775-530-5091
Mailing Address - Fax:
Practice Address - Street 1:222 SHOSHONE ST E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6105
Practice Address - Country:US
Practice Address - Phone:775-530-5091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5024225100000X
ID1715225X00000X
CO4285225X00000X
CO13347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist