Provider Demographics
NPI:1861583031
Name:BOSTIC, MARCIE (MS, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:MARCIE
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:MRS
Other - First Name:MARCIE
Other - Middle Name:
Other - Last Name:FIJEWSKI-EASTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:434 ALDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-2819
Mailing Address - Country:US
Mailing Address - Phone:304-661-1745
Mailing Address - Fax:
Practice Address - Street 1:434 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-2819
Practice Address - Country:US
Practice Address - Phone:304-661-1745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0816235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7401147000Medicaid
09148046OtherASHA CERTIFICATE OF CLINICAL COMPETENCE (AMERICAN SPEECH HEARING ASSOCIATION)
WVSLP-0816OtherWV BOARD OF EXAMINERS LICENSE FOR SPEECH PATHOLOGISTS AND AUDIOLOGISTS