Healthcare Provider Details

I. General information

NPI: 1902639495
Provider Name (Legal Business Name): ABHINAV S KOTARU RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W GRIMES LN
BLOOMINGTON IN
47403-3015
US

IV. Provider business mailing address

PO BOX 668
BLOOMINGTON IN
47402-0668
US

V. Phone/Fax

Practice location:
  • Phone: 812-322-0313
  • Fax:
Mailing address:
  • Phone: 812-322-0313
  • Fax: 812-610-1814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-370277
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: