Healthcare Provider Details

I. General information

NPI: 1154451185
Provider Name (Legal Business Name): DEBORAH W SERENIUS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 FAR HILLS AVE STE 108
DAYTON OH
45429-2227
US

IV. Provider business mailing address

5540 FAR HILLS AVE STE 108
DAYTON OH
45429-2227
US

V. Phone/Fax

Practice location:
  • Phone: 937-586-7644
  • Fax: 937-660-4575
Mailing address:
  • Phone: 937-586-7644
  • Fax: 937-660-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLD-4735
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL4735
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: