Basic Information
| Provider Information | |||||||||
| NPI: | 1235799412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLYARD | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLYARD | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2587 BACK ORRVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302649597 | ||||||||
| FaxNumber: | 3302640946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2587 BACK ORRVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302649597 | ||||||||
| FaxNumber: | 3302640946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | S.1903921 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.