Provider Demographics
NPI:1811394174
Name:BOERTJE, MARK (EDS, NCSP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BOERTJE
Suffix:
Gender:M
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 ROYAL DORNOCH CIR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3190
Mailing Address - Country:US
Mailing Address - Phone:740-815-3391
Mailing Address - Fax:
Practice Address - Street 1:3700 S HIGH ST
Practice Address - Street 2:SUITE 95
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4083
Practice Address - Country:US
Practice Address - Phone:740-815-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCC1003049171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCC1003049OtherOHIO DEPARTMENT OF EDUCATION