Provider Demographics
NPI:1326669086
Name:SPROUSE, DEJAH M (LPC)
Entity Type:Individual
Prefix:
First Name:DEJAH
Middle Name:M
Last Name:SPROUSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 IDLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2901
Mailing Address - Country:US
Mailing Address - Phone:440-420-9584
Mailing Address - Fax:
Practice Address - Street 1:1295 IDLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2901
Practice Address - Country:US
Practice Address - Phone:440-420-9584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X, 171M00000X
OHC.2304859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator