Healthcare Provider Details

I. General information

NPI: 1497793426
Provider Name (Legal Business Name): MARCIA R BOAL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 KAW DR
EDWARDSVILLE KS
66111-1170
US

IV. Provider business mailing address

10601 KAW DR
EDWARDSVILLE KS
66111-1170
US

V. Phone/Fax

Practice location:
  • Phone: 913-441-3030
  • Fax: 913-441-6940
Mailing address:
  • Phone: 913-441-3030
  • Fax: 913-441-6940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCSW771
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: