Healthcare Provider Details

I. General information

NPI: 1346489820
Provider Name (Legal Business Name): ROBIN BOOMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 MEDICAL DR
CARMEL IN
46032-2923
US

IV. Provider business mailing address

520 TAMARACK LN
NOBLESVILLE IN
46062-9528
US

V. Phone/Fax

Practice location:
  • Phone: 317-573-1037
  • Fax: 866-785-4924
Mailing address:
  • Phone: 317-258-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004593A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: