Provider Demographics
NPI:1649682717
Name:BOSOWSKI, ANDREA (IMF)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOSOWSKI
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11437 MONTICOOK CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-3128
Mailing Address - Country:US
Mailing Address - Phone:603-801-5054
Mailing Address - Fax:
Practice Address - Street 1:11437 MONTICOOK CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-3128
Practice Address - Country:US
Practice Address - Phone:603-801-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist