Healthcare Provider Details

I. General information

NPI: 1598820250
Provider Name (Legal Business Name): SUSAN DIX JIVIDEN OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

986 BELVEDERE DR SUITE B
LEBANON OH
45036-2890
US

IV. Provider business mailing address

967 HAMPTON CT
LEBANON OH
45036-8468
US

V. Phone/Fax

Practice location:
  • Phone: 513-934-1226
  • Fax: 513-934-1227
Mailing address:
  • Phone: 513-934-4498
  • Fax: 513-934-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT-01610
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: