Basic Information
| Provider Information | |||||||||
| NPI: | 1740563980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTROM | ||||||||
| FirstName: | MIRIAM | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 DAKOTA RIDGE LN | ||||||||
| Address2: | APT E | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462172822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122301494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 LIBRARY BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461421567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178819923 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 09/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.