Healthcare Provider Details

I. General information

NPI: 1265211338
Provider Name (Legal Business Name): SYREA THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 OFFICENTER PL STE 180
GAHANNA OH
43230-5321
US

IV. Provider business mailing address

540 OFFICENTER PL STE 180
GAHANNA OH
43230-5321
US

V. Phone/Fax

Practice location:
  • Phone: 216-310-4458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI.1500859-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1121378
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1500859-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: