Provider Demographics
NPI:1801397930
Name:BOSSERMAN, DUSTIN THOMAS (BT)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:THOMAS
Last Name:BOSSERMAN
Suffix:
Gender:M
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6073 THORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-9544
Mailing Address - Country:US
Mailing Address - Phone:916-289-4494
Mailing Address - Fax:
Practice Address - Street 1:1050 FULTON AVE STE 235
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4299
Practice Address - Country:US
Practice Address - Phone:916-974-2599
Practice Address - Fax:855-444-8901
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician