Provider Demographics
NPI:1720555246
Name:BOSWELL, STACI J (PTA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:J
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 COUNTY ROAD 58
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-9725
Mailing Address - Country:US
Mailing Address - Phone:816-262-6990
Mailing Address - Fax:
Practice Address - Street 1:1317 N 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2359
Practice Address - Country:US
Practice Address - Phone:816-676-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002001985225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant