Provider Demographics
NPI:1205975877
Name:ZOMBOREANU BOETTCHER, INGRID (MSW, LMSW)
Entity type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:
Last Name:ZOMBOREANU BOETTCHER
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35742 UNION LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-3178
Mailing Address - Country:US
Mailing Address - Phone:586-469-6606
Mailing Address - Fax:586-469-6364
Practice Address - Street 1:21885 DUNHAM RD.
Practice Address - Street 2:MCCMH - SRS STE 5
Practice Address - City:CLINTON TWP.
Practice Address - State:MI
Practice Address - Zip Code:48036
Practice Address - Country:US
Practice Address - Phone:586-469-6606
Practice Address - Fax:586-469-6364
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010801151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801080115OtherSTATE OF MI, BOARD OF SW