Provider Demographics
NPI:1174663850
Name:WETZLER, MARY ANN (LISW)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:WETZLER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 DERBYSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3342
Mailing Address - Country:US
Mailing Address - Phone:216-321-4309
Mailing Address - Fax:216-321-4309
Practice Address - Street 1:21625 CHAGRIN BLVD
Practice Address - Street 2:200
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5363
Practice Address - Country:US
Practice Address - Phone:440-473-9042
Practice Address - Fax:216-491-0155
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00006531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW03252Medicare PIN