Healthcare Provider Details

I. General information

NPI: 1124004957
Provider Name (Legal Business Name): ROBERT EUGENE REARDON PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GENE REARDON PH.D.

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18901 LAKE SHORE BLVD
EUCLID OH
44119-1078
US

IV. Provider business mailing address

18901 LAKE SHORE BLVD
EUCLID OH
44119-1078
US

V. Phone/Fax

Practice location:
  • Phone: 216-531-9000
  • Fax: 216-274-9629
Mailing address:
  • Phone: 216-531-9000
  • Fax: 216-274-9629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5001
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: