Basic Information
| Provider Information | |||||||||
| NPI: | 1164910451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEDON | ||||||||
| FirstName: | THERESE | ||||||||
| MiddleName: | ANNE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LORSON | ||||||||
| OtherFirstName: | THERESE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CDCA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 625 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304550374 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 SPRING AVE NE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447142349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304546800 | ||||||||
| FaxNumber: | 3305887176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2018 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA166669 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.