Provider Demographics
NPI:1932296795
Name:CORDASCO, MARTHA ANN (MSSA LISW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:ANN
Last Name:CORDASCO
Suffix:
Gender:F
Credentials:MSSA LISW
Other - Prefix:MRS
Other - First Name:MARTHA
Other - Middle Name:ANN
Other - Last Name:CORDASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSSA LISW
Mailing Address - Street 1:627 S EDWIN C MOSES BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3461
Mailing Address - Country:US
Mailing Address - Phone:937-424-1000
Mailing Address - Fax:937-424-1002
Practice Address - Street 1:627 S EDWIN C MOSES BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3461
Practice Address - Country:US
Practice Address - Phone:937-424-1000
Practice Address - Fax:937-424-1002
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI43061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378658Medicaid
OH057102OtherVALUE OPTIONS
OH6255128OtherUBH
OH346772000OtherMAGELLAN
OH006OtherMEDICAL MUTUAL
OH000000357983OtherANTHEM
OH311827OtherMHN
OH7727350OtherAETNA
OH6255128OtherUBH