Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1104274232 |
---|---|
Provider Name | Dr. Tyrone Bostic |
First Address | Indianapolis, IN 46220-5659 |
Second Address | Indianapolis, IN 46220-5659 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2016 |
Last Update Date | 31/05/2016 |