Provider Demographics
NPI:1659453033
Name:SPITZNAGEL, MARY BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
Last Name:SPITZNAGEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1462
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-0462
Mailing Address - Country:US
Mailing Address - Phone:330-379-8148
Mailing Address - Fax:330-379-8149
Practice Address - Street 1:75 ARCH ST
Practice Address - Street 2:SUITE G2
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1429
Practice Address - Country:US
Practice Address - Phone:330-375-3747
Practice Address - Fax:330-375-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6123103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2877552Medicaid
OHCP31292Medicare PIN