Individual
AMY DETRICK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
421 KIRKWOOD DR, FAIRBORN, OH 45324-4429
(770) 878-7179
Mailing address
421 KIRKWOOD DR, FAIRBORN, OH 45324-4429
(770) 878-7179
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0157443
—
OH
Enumeration date
11/23/2020
Last updated
11/23/2020
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