Healthcare Provider Details

I. General information

NPI: 1871632182
Provider Name (Legal Business Name): ENLIGHTENED THERAPY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 COMMONS BLVD SUITE 240
BEAVERCREEK OH
45431-3809
US

IV. Provider business mailing address

77 E WOODBURY DR SUITE 106
DAYTON OH
45415-2855
US

V. Phone/Fax

Practice location:
  • Phone: 937-429-8620
  • Fax: 937-429-8629
Mailing address:
  • Phone: 937-278-1779
  • Fax: 937-278-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUDITH ANN O'CONNELL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 937-278-1779