Healthcare Provider Details

I. General information

NPI: 1043578487
Provider Name (Legal Business Name): MARY THERESA MASSIE MSW LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY THERESA RITCHEY MSW LISW-S

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 OLD HENDERSON RD SUITE 100
COLUMBUS OH
43220-3623
US

IV. Provider business mailing address

1170 OLD HENDERSON RD SUITE 100
COLUMBUS OH
43220-3623
US

V. Phone/Fax

Practice location:
  • Phone: 614-442-7650
  • Fax: 614-442-7656
Mailing address:
  • Phone: 614-442-7650
  • Fax: 614-442-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0005567 SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: