Provider Demographics
NPI:1023567559
Name:DITZEL, SARA RAYE (MSP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:RAYE
Last Name:DITZEL
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7591 TYLERS PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-6308
Mailing Address - Country:US
Mailing Address - Phone:513-755-6600
Mailing Address - Fax:
Practice Address - Street 1:3817 COLONEL GLENN HWY
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45324-2031
Practice Address - Country:US
Practice Address - Phone:937-427-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6080235Z00000X
OHSP12795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAB7360731OtherMEDICARE PIN
OH2187155Medicaid