Provider Demographics
NPI:1659033694
Name:BEREZA, JOHN MATTHEW (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:BEREZA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 S FRONT ST APT 415
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5104
Mailing Address - Country:US
Mailing Address - Phone:614-299-9652
Mailing Address - Fax:
Practice Address - Street 1:272 S FRONT ST APT 415
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5104
Practice Address - Country:US
Practice Address - Phone:614-299-9652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool