Provider Demographics
NPI:1235647603
Name:BOULET, BETH (SWA)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:BOULET
Suffix:
Gender:F
Credentials:SWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2529
Mailing Address - Country:US
Mailing Address - Phone:740-435-9766
Mailing Address - Fax:740-432-4966
Practice Address - Street 1:152 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1004
Practice Address - Country:US
Practice Address - Phone:740-435-9766
Practice Address - Fax:740-432-4966
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.1600027104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker