Provider Demographics
NPI:1831717073
Name:BOEKE GANZELL, MARIBETH ROSE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MARIBETH
Middle Name:ROSE
Last Name:BOEKE GANZELL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48836 PARK PINES DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-3515
Mailing Address - Country:US
Mailing Address - Phone:909-241-2853
Mailing Address - Fax:
Practice Address - Street 1:18952 E FISHER RD
Practice Address - Street 2:
Practice Address - City:ST MARYS CITY
Practice Address - State:MD
Practice Address - Zip Code:20686-3001
Practice Address - Country:US
Practice Address - Phone:909-241-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA002472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer