Provider Demographics
NPI:1285637389
Name:BOAZ, DELORA K (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:DELORA
Middle Name:K
Last Name:BOAZ
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1716
Mailing Address - Country:US
Mailing Address - Phone:502-583-3951
Mailing Address - Fax:
Practice Address - Street 1:600 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1716
Practice Address - Country:US
Practice Address - Phone:502-583-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1369104100000X
KY0008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65927857Medicaid
50704000OtherMAGELLAN MIS GROUP
701764000OtherMAGELLAN MIS
KY82000902Medicaid
KY2748490000OtherPASSPORT ADVANTAGE
KY2748490000OtherPASSPORT GROUP
KY82900176Medicaid
KYCK2274OtherMEDICARE RAILROAD GROUP
000000056294OtherANTHEM GROUP
KY78903689Medicaid
000000312667OtherANTHEM
KY6764OtherMEDICARE GROUP
KY0676439Medicare ID - Type Unspecified