Provider Demographics
NPI:1396866851
Name:DEPERRO, MARY D (LISW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:DEPERRO
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:PO BOX 45519
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-0519
Mailing Address - Country:US
Mailing Address - Phone:800-514-4390
Mailing Address - Fax:440-808-3675
Practice Address - Street 1:3957 LOOMIS PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1804
Practice Address - Country:US
Practice Address - Phone:330-697-7403
Practice Address - Fax:330-645-6935
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00049201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDESW20682Medicare ID - Type Unspecified