Provider Demographics
NPI:1750931101
Name:DANZY, DESIRAE NICHOLE
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:NICHOLE
Last Name:DANZY
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 1:3175 RANDALL WAY APT 14
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-7500
Mailing Address - Country:US
Mailing Address - Phone:574-220-9555
Mailing Address - Fax:
Practice Address - Street 1:301 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-3324
Practice Address - Country:US
Practice Address - Phone:937-854-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist