Healthcare Provider Details

I. General information

NPI: 1063815389
Provider Name (Legal Business Name): LAURIE SUSAN ALLEN OTR CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 S CLARIZZ BLVD
BLOOMINGTON IN
47401-5515
US

IV. Provider business mailing address

2605 E CREEKS EDGE DR
BLOOMINGTON IN
47401-8368
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-2663
  • Fax: 812-349-9206
Mailing address:
  • Phone: 812-333-2663
  • Fax: 812-349-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number31000726A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000726A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: