Healthcare Provider Details

I. General information

NPI: 1457861361
Provider Name (Legal Business Name): UNTAPPED - PEDIATRIC THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14194 STACEY ST
CARMEL IN
46033-8720
US

IV. Provider business mailing address

14194 STACEY ST
CARMEL IN
46033-8720
US

V. Phone/Fax

Practice location:
  • Phone: 317-753-6962
  • Fax:
Mailing address:
  • Phone: 317-753-6962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004103A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIFFANY MARIE FRITZ
Title or Position: OWNER/CEO/OCCUPATIONAL THERAPIST
Credential: OTR
Phone: 317-753-6962