Provider Demographics
NPI:1619443157
Name:BOSSO, DAVID ISHMAEL
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ISHMAEL
Last Name:BOSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 6TH AVE S APT E101
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5890
Mailing Address - Country:US
Mailing Address - Phone:253-334-8641
Mailing Address - Fax:
Practice Address - Street 1:1033 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1845
Practice Address - Country:US
Practice Address - Phone:206-242-1698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health