Provider Demographics
NPI:1912631029
Name:AZAR, MARY REED (SWT, QMHS-3)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:REED
Last Name:AZAR
Suffix:
Gender:F
Credentials:SWT, QMHS-3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 HENTHORNE DR STE C
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1370
Mailing Address - Country:US
Mailing Address - Phone:419-491-0420
Mailing Address - Fax:567-698-7875
Practice Address - Street 1:1627 HENTHORNE DR STE C
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1370
Practice Address - Country:US
Practice Address - Phone:419-491-0420
Practice Address - Fax:567-698-7875
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2202505-TRNE390200000X
104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496080Medicaid