Healthcare Provider Details

I. General information

NPI: 1497257695
Provider Name (Legal Business Name): MARY LOU REDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 W MARKET ST
WARREN OH
44485-3069
US

IV. Provider business mailing address

1556 COLLAR PRICE RD
HUBBARD OH
44425-2917
US

V. Phone/Fax

Practice location:
  • Phone: 330-898-6992
  • Fax: 330-898-6796
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: