Provider Demographics
NPI:1396371506
Name:DURIVAGE, HEATHER DAWN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:DURIVAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DAWN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10296 SPRINGFIELD PIKE STE 500
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1194
Mailing Address - Country:US
Mailing Address - Phone:614-339-1651
Mailing Address - Fax:614-339-1751
Practice Address - Street 1:934 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1912
Practice Address - Country:US
Practice Address - Phone:513-831-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-19-109452106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician