Provider Demographics
NPI:1982214698
Name:BOENAU, MARTHA ELIZABETH (LGPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELIZABETH
Last Name:BOENAU
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4855
Mailing Address - Country:US
Mailing Address - Phone:240-888-9642
Mailing Address - Fax:
Practice Address - Street 1:319 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4855
Practice Address - Country:US
Practice Address - Phone:240-888-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health