Provider Demographics
NPI:1578165338
Name:CLEARY, DEBORAH ANN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ANN
Last Name:CLEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-2410
Mailing Address - Country:US
Mailing Address - Phone:937-212-9606
Mailing Address - Fax:
Practice Address - Street 1:2412 FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-2410
Practice Address - Country:US
Practice Address - Phone:937-212-9606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2022-10-20
Deactivation Date:2022-10-08
Deactivation Code:
Reactivation Date:2022-10-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5718622Medicaid