Healthcare Provider Details

I. General information

NPI: 1619061371
Provider Name (Legal Business Name): ANGELA M. CARRUTH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA M. DIX PSY.D.

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5350 LAMME RD
MORAINE OH
45439-3215
US

IV. Provider business mailing address

2110 LEITER RD
MIAMISBURG OH
45342-3660
US

V. Phone/Fax

Practice location:
  • Phone: 937-534-4651
  • Fax: 937-534-4609
Mailing address:
  • Phone: 937-914-7054
  • Fax: 937-522-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5483
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: