Provider Demographics
NPI:1891300653
Name:SANDUSKY, SHYLIEN RANAE (BA)
Entity Type:Individual
Prefix:
First Name:SHYLIEN
Middle Name:RANAE
Last Name:SANDUSKY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7691 POE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2552
Mailing Address - Country:US
Mailing Address - Phone:614-339-1649
Mailing Address - Fax:
Practice Address - Street 1:9260 MARKETPLACE DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-4478
Practice Address - Country:US
Practice Address - Phone:937-388-5110
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-19-107626106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid