Provider Demographics
NPI:1366708521
Name:BOSWELL, DIANA M (MCD, CCC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:MCD, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4191 WASH LEE CT SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7440
Mailing Address - Country:US
Mailing Address - Phone:770-935-7613
Mailing Address - Fax:
Practice Address - Street 1:4191 WASH LEE CT SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-7440
Practice Address - Country:US
Practice Address - Phone:770-935-7613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist