Provider Demographics
NPI:1699559385
Name:REARDON, MICHAEL CHARLES
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:REARDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 WORK RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-8324
Mailing Address - Country:US
Mailing Address - Phone:234-263-8036
Mailing Address - Fax:
Practice Address - Street 1:370 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1526
Practice Address - Country:US
Practice Address - Phone:330-535-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRA.163682405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional