Provider Demographics
NPI:1104637628
Name:SUPERS, RENEE E (LSW)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:E
Last Name:SUPERS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 CANTERBURY LN APT A
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-4033
Mailing Address - Country:US
Mailing Address - Phone:330-321-2018
Mailing Address - Fax:
Practice Address - Street 1:22540 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2212
Practice Address - Country:US
Practice Address - Phone:440-734-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0030839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker