MEDICARE: 123OT, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1902438856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	123OT, LLP

Provider Business Mailing Address
First Line	:	10335 CORYDON CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46239-9781
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10335 CORYDON CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46239-9781
Country	:	US
Telephone Number	:	317-437-0848
Fax Number	:

Authorized Official
Title or Position	:	COTA
Name	:	STACI LEDET
Credential	:
Telephone Number	:	260-243-1198

Provider Enumeration Date	:	02/09/2020
Last Update Date	:	02/09/2020

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