Provider Demographics
NPI:1992193619
Name:BOSWELL, COURTNEY ROSE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ROSE
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 RIVER PARK DR STE 285
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4522
Mailing Address - Country:US
Mailing Address - Phone:877-264-6747
Mailing Address - Fax:
Practice Address - Street 1:495 SEAPORT CT STE 102
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2785
Practice Address - Country:US
Practice Address - Phone:877-264-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1149751103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst