Provider Demographics
NPI:1689151557
Name:WANTZ, MOLLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:WANTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12443 WOODIN RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9130
Mailing Address - Country:US
Mailing Address - Phone:440-725-0920
Mailing Address - Fax:
Practice Address - Street 1:12443 WOODIN RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9130
Practice Address - Country:US
Practice Address - Phone:440-725-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-18-31347103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst