Provider Demographics
NPI:1932329729
Name:BOSWORTH, THERESA MARIE (MA,CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MICHIGAN NE SUITE A
Mailing Address - Street 2:GRAND RAPIDS EAR NOSE & THROAT, PC
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-459-7749
Mailing Address - Fax:616-459-5001
Practice Address - Street 1:1425 MICHIGAN NE SUITE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-459-4514
Practice Address - Fax:616-459-5001
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000098231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640D126260OtherBLUE SHIELD HEARING PROVI