Provider Demographics
NPI:1497793426
Name:BOAL, MARCIA R (MSW)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:R
Last Name:BOAL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 KAW DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66111-1170
Mailing Address - Country:US
Mailing Address - Phone:913-441-3030
Mailing Address - Fax:913-441-6940
Practice Address - Street 1:10601 KAW DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66111-1170
Practice Address - Country:US
Practice Address - Phone:913-441-3030
Practice Address - Fax:913-441-6940
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW7711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSQ47613Medicare UPIN
KS000D0972Medicare ID - Type Unspecified