Basic Information
Provider Information | |||||||||
NPI: | 1891300653 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDUSKY | ||||||||
FirstName: | SHYLIEN | ||||||||
MiddleName: | RANAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7691 POE AVE | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454142552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143391649 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9260 MARKETPLACE DR | ||||||||
Address2: |   | ||||||||
City: | MIAMISBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 453424478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373885110 | ||||||||
FaxNumber: | 3175208200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2020 | ||||||||
LastUpdateDate: | 02/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-107626 | OH | N |   |   |   |   | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 2910854 | 05 | OH |   | MEDICAID |