Provider Demographics
NPI:1134244882
Name:BOSCH, DEBRA M (LICSW)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:M
Last Name:BOSCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N MANDAN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3886
Mailing Address - Country:US
Mailing Address - Phone:701-323-0924
Mailing Address - Fax:701-323-0935
Practice Address - Street 1:1701 BURNT BOAT DR
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0812
Practice Address - Country:US
Practice Address - Phone:701-323-0924
Practice Address - Fax:701-323-0935
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND16501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDBOS20308OtherBCBS OF NORTH DAKOTA
ND18726Medicaid
NDN20308Medicare PIN
ND18726Medicaid