Healthcare Provider Details

I. General information

NPI: 1447926092
Provider Name (Legal Business Name): REDINA LEE COUNCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL FL 3
DAYTON OH
45417-3445
US

IV. Provider business mailing address

216 COLLEGE ST APT C
DAYTON OH
45402-6903
US

V. Phone/Fax

Practice location:
  • Phone: 937-903-3376
  • Fax:
Mailing address:
  • Phone: 937-409-0418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002040
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: