Provider Demographics
NPI:1689003667
Name:BOETZ, MANDY R (LSW)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:R
Last Name:BOETZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1943 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1158
Mailing Address - Country:US
Mailing Address - Phone:614-253-8050
Mailing Address - Fax:614-253-8066
Practice Address - Street 1:1751 E LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-2045
Practice Address - Country:US
Practice Address - Phone:614-253-8050
Practice Address - Fax:614-253-8066
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1302384104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.1302384Medicaid