Healthcare Provider Details

I. General information

NPI: 1053009944
Provider Name (Legal Business Name): ANNE MARI GRACE WEST OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1353 E MAIN ST
BROWNSBURG IN
46112-1433
US

IV. Provider business mailing address

3140 JOANN ST
PORTAGE IN
46368-3954
US

V. Phone/Fax

Practice location:
  • Phone: 317-520-4748
  • Fax:
Mailing address:
  • Phone: 219-771-5580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: