Basic Information
| Provider Information | |||||||||
| NPI: | 1689003667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOETZ | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1943 NORTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432121158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
| FaxNumber: | 6142538066 | ||||||||
| Practice Location | |||||||||
| Address1: | 1751 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432032045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
| FaxNumber: | 6142538066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2013 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1302384 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | S.1302384 | 05 | OH | MEDICAID |