Provider Demographics
NPI:1922584408
Name:BOZEMAN, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:BOZEMAN
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 1:25338 WALNUT ST SPC 22
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1972
Mailing Address - Country:US
Mailing Address - Phone:424-285-9411
Mailing Address - Fax:
Practice Address - Street 1:3521 LOMITA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5040
Practice Address - Country:US
Practice Address - Phone:310-856-8528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48882355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty