1043804602 NPI number — KEIGHT NEOMA DIJKSTRA MSW, LSW

Table of content: KEIGHT NEOMA DIJKSTRA MSW, LSW (NPI 1043804602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043804602 NPI number — KEIGHT NEOMA DIJKSTRA MSW, LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIJKSTRA
Provider First Name:
KEIGHT
Provider Middle Name:
NEOMA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YUELLIG
Provider Other First Name:
MARY
Provider Other Middle Name:
KATHRYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043804602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 396
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45066-0396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-575-6227
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3012 GLENMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45238-2269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-575-6227
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: S.2207408 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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