Healthcare Provider Details

I. General information

NPI: 1396371506
Provider Name (Legal Business Name): HEATHER DAWN DURIVAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER DAWN MARTIN

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 STATE ROUTE 28
MILFORD OH
45150-1912
US

IV. Provider business mailing address

10296 SPRINGFIELD PIKE STE 500
CINCINNATI OH
45215-1194
US

V. Phone/Fax

Practice location:
  • Phone: 513-831-1770
  • Fax:
Mailing address:
  • Phone: 614-339-1651
  • Fax: 614-339-1751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-109452
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: