Provider Demographics
NPI:1659463149
Name:SERAZIN, REBECCA (PHD PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SERAZIN
Suffix:
Gender:F
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 POLE AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-4301
Mailing Address - Country:US
Mailing Address - Phone:440-960-5800
Mailing Address - Fax:
Practice Address - Street 1:2350 POLE AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4301
Practice Address - Country:US
Practice Address - Phone:440-960-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3676103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7255198Medicaid
OH7255198Medicaid