Provider Demographics
NPI:1831340777
Name:BOSILJEVAC, TERESA RUSSELL (AUD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:RUSSELL
Last Name:BOSILJEVAC
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 SPICEWOOD CLUB DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-2858
Mailing Address - Country:US
Mailing Address - Phone:510-295-3593
Mailing Address - Fax:
Practice Address - Street 1:11109 SPICEWOOD CLUB DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2858
Practice Address - Country:US
Practice Address - Phone:510-295-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81217231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81217OtherTX AUDIOLOGY LICENSE NUMBER