Provider Demographics
NPI:1336626555
Name:ZEREN, KRISTINA MARIE (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:ZEREN
Suffix:
Gender:F
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 ALTA PL NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-1238
Mailing Address - Country:US
Mailing Address - Phone:330-704-4459
Mailing Address - Fax:
Practice Address - Street 1:1711 SPRING AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2349
Practice Address - Country:US
Practice Address - Phone:330-454-6800
Practice Address - Fax:330-588-7176
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA170821101YA0400X
OHS1803100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0351930Medicaid