Provider Demographics
NPI:1730792722
Name:BOSTIC, ARYN (MA, LPC, CD-PICD)
Entity type:Individual
Prefix:MS
First Name:ARYN
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:MA, LPC, CD-PICD
Other - Prefix:MS
Other - First Name:AJ
Other - Middle Name:
Other - Last Name:BOSTIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC, CD-PICD
Mailing Address - Street 1:2055 CRAIGSHIRE RD STE 420A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4036
Mailing Address - Country:US
Mailing Address - Phone:314-440-1829
Mailing Address - Fax:
Practice Address - Street 1:2055 CRAIGSHIRE RD STE 420A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4036
Practice Address - Country:US
Practice Address - Phone:314-440-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020027892101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional