Healthcare Provider Details

I. General information

NPI: 1316363120
Provider Name (Legal Business Name): RANDOLPH SCOTT REPOSA LPC-CR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 BENDEN DR
WOOSTER OH
44691-2568
US

IV. Provider business mailing address

549 MARKET ST NE
NAVARRE OH
44662-1049
US

V. Phone/Fax

Practice location:
  • Phone: 330-264-9029
  • Fax: 330-263-7251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: