Provider Demographics
NPI:1255821567
Name:REICHARD, MARA ASHTON (MSW, LSW)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:ASHTON
Last Name:REICHARD
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 BIG HILL RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45439-2219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1785 BIG HILL RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45439-2219
Practice Address - Country:US
Practice Address - Phone:937-264-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.17009721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3119646Medicaid