Healthcare Provider Details

I. General information

NPI: 1285075572
Provider Name (Legal Business Name): MARY KOTLAREK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 SUMMIT AVE
TROY OH
45373-3047
US

IV. Provider business mailing address

665 N HYATT ST APT. H
TIPP CITY OH
45371-1573
US

V. Phone/Fax

Practice location:
  • Phone: 937-335-7148
  • Fax:
Mailing address:
  • Phone: 937-397-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0025198
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: