Provider Demographics
NPI:1205168648
Name:BOSCH, CAROL SUE (MS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:SUE
Last Name:BOSCH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:SUE
Other - Last Name:BOSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:924 TWIN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8749
Mailing Address - Country:US
Mailing Address - Phone:209-830-7049
Mailing Address - Fax:209-830-7049
Practice Address - Street 1:4212 N PERSHING AVE
Practice Address - Street 2:#A1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6952
Practice Address - Country:US
Practice Address - Phone:209-957-3900
Practice Address - Fax:209-672-9440
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist