Healthcare Provider Details

I. General information

NPI: 1992225148
Provider Name (Legal Business Name): MAPLE TREE CANCER ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 PENTAGON BLVD
BEAVERCREEK OH
45431-1705
US

IV. Provider business mailing address

425 N FINDLAY ST
DAYTON OH
45404-2203
US

V. Phone/Fax

Practice location:
  • Phone: 937-477-8213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KAREN Y WONDERS
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 937-477-8213