Healthcare Provider Details

I. General information

NPI: 1508721150
Provider Name (Legal Business Name): ANDEE KOCZAK RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8559 INNSBROOK LN
SPRINGBORO OH
45066-9626
US

IV. Provider business mailing address

8559 INNSBROOK LN
SPRINGBORO OH
45066-9626
US

V. Phone/Fax

Practice location:
  • Phone: 937-657-2985
  • Fax: 937-657-2985
Mailing address:
  • Phone: 937-657-2985
  • Fax: 937-657-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1325
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: