Provider Demographics
NPI:1659695401
Name:ANGELA BOMMARITO LISW LLC
Entity Type:Organization
Organization Name:ANGELA BOMMARITO LISW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BOMMARITO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LISW-S
Authorized Official - Phone:614-270-0910
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-0902
Mailing Address - Country:US
Mailing Address - Phone:614-270-0910
Mailing Address - Fax:
Practice Address - Street 1:167 S STATE ST STE 120
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2278
Practice Address - Country:US
Practice Address - Phone:614-270-0910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0700030 SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497880900OtherINDIVIDUAL TYPE 1 NPI