Provider Demographics
NPI:1093157232
Name:ECKENRODE, REBECCA M (LISW-S)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:ECKENRODE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32640 SPINNAKER DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2110
Mailing Address - Country:US
Mailing Address - Phone:440-479-3300
Mailing Address - Fax:
Practice Address - Street 1:2639 WOOSTER RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2911
Practice Address - Country:US
Practice Address - Phone:440-479-3308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI17003341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid