Provider Demographics
NPI:1265309934
Name:BOSWORTH, IRELAND SUSANNAH
Entity type:Individual
Prefix:
First Name:IRELAND
Middle Name:SUSANNAH
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 WALLER RD E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98443-1418
Mailing Address - Country:US
Mailing Address - Phone:253-252-9293
Mailing Address - Fax:
Practice Address - Street 1:4624 WALLER RD E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98443-1418
Practice Address - Country:US
Practice Address - Phone:253-252-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-18
Last Update Date:2025-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB70022307106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician