Provider Demographics
NPI:1740563980
Name:BOSTROM, MIRIAM (MA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BOSTROM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 DAKOTA RIDGE LN
Mailing Address - Street 2:APT E
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-2822
Mailing Address - Country:US
Mailing Address - Phone:812-230-1494
Mailing Address - Fax:
Practice Address - Street 1:1701 LIBRARY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1567
Practice Address - Country:US
Practice Address - Phone:317-881-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist