Healthcare Provider Details

I. General information

NPI: 1457231185
Provider Name (Legal Business Name): MACY JEAN METZGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 SOUTHERN BLVD BLDG E
BOARDMAN OH
44512-3455
US

IV. Provider business mailing address

3365 PARTRIDGE PARK DR
POLAND OH
44514-2808
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-5015
  • Fax:
Mailing address:
  • Phone: 330-301-5106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2506756
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: