Provider Demographics
NPI:1013092345
Name:BOSTIC, ELIZABETH MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 OLD MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-7511
Mailing Address - Country:US
Mailing Address - Phone:434-799-3318
Mailing Address - Fax:434-799-3318
Practice Address - Street 1:1611 OLD MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-7511
Practice Address - Country:US
Practice Address - Phone:434-799-3318
Practice Address - Fax:434-799-3318
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040020391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical