Provider Demographics
NPI:1447481643
Name:BOSSARD, LUCAS OWEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:OWEN
Last Name:BOSSARD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-1281
Mailing Address - Fax:
Practice Address - Street 1:794 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6856
Practice Address - Country:US
Practice Address - Phone:208-734-1281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202292103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical