Provider Demographics
NPI:1053474593
Name:WANTUCK, EDWARD MICHAEL (MSW LISW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MICHAEL
Last Name:WANTUCK
Suffix:
Gender:M
Credentials:MSW LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 AUBURN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-241-1811
Mailing Address - Fax:513-241-2112
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-241-1811
Practice Address - Fax:513-241-2112
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0004141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical