Provider Demographics
NPI:1003106907
Name:RERUCHA, MARLENE
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:RERUCHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 HENTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1371
Mailing Address - Country:US
Mailing Address - Phone:419-866-5275
Mailing Address - Fax:
Practice Address - Street 1:1560 HENTHORNE DR
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1371
Practice Address - Country:US
Practice Address - Phone:419-866-5275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP8352235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1609899061OtherCORPORATE NPI