Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
N | 101YP2500X | Professional Counselor | ||
Y | 101YP2500X | Professional Counselor | P2010088 | AR |
NPI | 1003138710 |
---|---|
Provider Name | Trebor Wellington Bosley |
First Address | Jonesboro, AR 72405-7870 |
Second Address | Jonesboro, AR 72405-7870 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2010 |
Last Update Date | 29/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101YM0800X | (05) | OK |