Healthcare Provider Details

I. General information

NPI: 1265550453
Provider Name (Legal Business Name): MARY SPIEHLER OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 S GLASGOW CIRCLE
BLOOMINGTON IN
47403-2629
US

IV. Provider business mailing address

3624 S GLASGOW CIRCLE
BLOOMINGTON IN
47403-2629
US

V. Phone/Fax

Practice location:
  • Phone: 812-340-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002685A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8812
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004655A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number110111
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: