MEDICARE: MRS. SHATEERA GAGE CCHW, MHA, BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	CHW.001704	OH

General Provider Information

NPI Number	:	1548027154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHATEERA GAGE CCHW, MHA, BS

Provider Business Mailing Address
First Line	:	2750 RIDGE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-5433
Country	:	US
Telephone Number	:	513-265-5075
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 RIDGE AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-5433
Country	:	US
Telephone Number	:	513-265-5075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2024
Last Update Date	:	02/29/2024

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