Provider Demographics
NPI:1730310715
Name:BOSTICK, ELIZABETH M
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1624
Mailing Address - Country:US
Mailing Address - Phone:573-682-2283
Mailing Address - Fax:573-682-1369
Practice Address - Street 1:635 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1624
Practice Address - Country:US
Practice Address - Phone:573-682-2283
Practice Address - Fax:573-682-1369
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO46895007Medicaid