Provider Demographics
NPI:1770795148
Name:MAUTZ, JANICE IRENE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:IRENE
Last Name:MAUTZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 OLD LANE AVE
Mailing Address - Street 2:APT. 3
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1729
Mailing Address - Country:US
Mailing Address - Phone:937-395-9711
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-1921
Practice Address - Country:US
Practice Address - Phone:937-643-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical