Basic Information
Provider Information
NPI: 1619319738
EntityType: 2
ReplacementNPI:  
OrganizationName: T.W. BOSLEY LLC
LastName:  
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Mailing Information
Address1: 4421 APPLE BLOSSOM CIR
Address2:  
City: MOORE
State: OK
PostalCode: 731601007
CountryCode: US
TelephoneNumber: 4055351048
FaxNumber:  
Practice Location
Address1: 115 S PETERS AVE
Address2: SUITE 11
City: NORMAN
State: OK
PostalCode: 730696065
CountryCode: US
TelephoneNumber: 4055351048
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/18/2013
LastUpdateDate: 07/18/2013
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: BOSLEY
AuthorizedOfficialFirstName: TREBOR
AuthorizedOfficialMiddleName: WELLINGTON
AuthorizedOfficialTitleorPosition: OWNER/ THERAPIST
AuthorizedOfficialTelephone: 4055351048
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.H.R., L.P.C.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X4759OKY193400000X SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorProfessional

ID Information
IDTypeStateIssuerDescription
100313871001 PERSONAL PROVIDER NPI NUMBEROTHER


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