Provider Demographics
NPI:1639835812
Name:BERRY, REBECCA E (LICDC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:BERRY
Suffix:
Gender:
Credentials:LICDC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:E
Other - Last Name:WEIHROUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-2850
Practice Address - Country:US
Practice Address - Phone:440-821-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162731101YA0400X, 101YA0400X
OHCDCA.182479101YA0400X
OHLCDCII.161927101YA0400X
CDCA.178154101YM0800X, 1041S0200X
OHS.2102159-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.178154OtherCHEMICAL DEPENDENCY PROFESSIONALS BOARD