Healthcare Provider Details

I. General information

NPI: 1215645890
Provider Name (Legal Business Name): BLADE MILLS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E COURT ST
SIDNEY OH
45365-3021
US

IV. Provider business mailing address

129 E COURT ST
SIDNEY OH
45365-3021
US

V. Phone/Fax

Practice location:
  • Phone: 937-498-1354
  • Fax: 937-498-4850
Mailing address:
  • Phone: 937-498-1354
  • Fax: 937-498-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.03259
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: