=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205975877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID ZOMBOREANU BOETTCHER MSW, LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21885 DUNHAM RD. MCCMH - SRS STE 5
-----------------------------------------------------
City | CLINTON TWP.
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-469-6606
-----------------------------------------------------
Fax | 586-469-6364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35742 UNION LAKE RD
-----------------------------------------------------
City | HARRISON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48045-3178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-469-6606
-----------------------------------------------------
Fax | 586-469-6364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801080115
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------