Healthcare Provider Details

I. General information

NPI: 1366704561
Provider Name (Legal Business Name): JEANETTE RUTH REDENIUS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STATE ST SUITE 202
ERIE PA
16507-1452
US

IV. Provider business mailing address

2150 W 8TH ST APARTMENT #5
ERIE PA
16505-4756
US

V. Phone/Fax

Practice location:
  • Phone: 814-480-8797
  • Fax: 814-459-2303
Mailing address:
  • Phone: 814-504-7448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW128381
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: