Provider Demographics
NPI:1093157232
Name:KONDRICH, REBECCA M (LISW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:KONDRICH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 LANDINGS WAY
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2236
Mailing Address - Country:US
Mailing Address - Phone:440-479-3300
Mailing Address - Fax:
Practice Address - Street 1:20088 CENTER RIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116
Practice Address - Country:US
Practice Address - Phone:440-479-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI17003341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid