Provider Demographics
NPI:1457981631
Name:BOSTICK, OMONI L
Entity Type:Individual
Prefix:
First Name:OMONI
Middle Name:L
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-261-1000
Mailing Address - Fax:210-261-1821
Practice Address - Street 1:6812 BANDERA RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1378
Practice Address - Country:US
Practice Address - Phone:210-261-3350
Practice Address - Fax:210-261-1794
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80018101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional