Provider Demographics
NPI:1619061371
Name:CARRUTH, ANGELA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:CARRUTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:DIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-914-7054
Mailing Address - Fax:937-522-7685
Practice Address - Street 1:5350 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4651
Practice Address - Fax:937-534-4609
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2859536Medicaid
OHCACP33551Medicare PIN