Provider Demographics
NPI:1538182662
Name:REALE, JEFFREY LYNN (PT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LYNN
Last Name:REALE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:850 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9668
Practice Address - Country:US
Practice Address - Phone:330-877-3488
Practice Address - Fax:330-877-4147
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 004856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000134699OtherANTHEM BC/BS