Provider Demographics
NPI:1356131452
Name:BOSAK, GABRIELLE NICOLE (PT, DPT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:NICOLE
Last Name:BOSAK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 CAMP RD APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3752
Mailing Address - Country:US
Mailing Address - Phone:843-754-4431
Mailing Address - Fax:
Practice Address - Street 1:1014 SAINT ANDREWS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7177
Practice Address - Country:US
Practice Address - Phone:843-985-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist