Provider Demographics
NPI:1780836668
Name:BOSHOFF, EDWARD R
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:BOSHOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2924
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-2984
Mailing Address - Country:US
Mailing Address - Phone:301-609-9887
Mailing Address - Fax:301-609-7284
Practice Address - Street 1:6100 RADIO STATION ROAD
Practice Address - Street 2:
Practice Address - City:LAPLATA
Practice Address - State:MD
Practice Address - Zip Code:20646
Practice Address - Country:US
Practice Address - Phone:301-609-9887
Practice Address - Fax:301-609-7284
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD58956180Medicaid
MD941L70Medicare UPIN