Provider Demographics
NPI:1164710646
Name:BOYER, KATHLEEN MARIE (DIRECTOR)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BOYER
Suffix:
Gender:F
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3218
Mailing Address - Country:US
Mailing Address - Phone:330-926-1118
Mailing Address - Fax:330-926-1131
Practice Address - Street 1:2044 FRONT ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-3218
Practice Address - Country:US
Practice Address - Phone:330-926-1118
Practice Address - Fax:330-926-1131
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OH1611854172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2704961Medicaid