Healthcare Provider Details

I. General information

NPI: 1952845406
Provider Name (Legal Business Name): PEDIATRIC THERAPY OF INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 S COUNTY ROAD 800 W
DALEVILLE IN
47334-9420
US

IV. Provider business mailing address

10653 KESTREL CT
NOBLESVILLE IN
46060-7537
US

V. Phone/Fax

Practice location:
  • Phone: 317-379-1794
  • Fax: 317-770-0535
Mailing address:
  • Phone: 317-379-1794
  • Fax: 317-770-0535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number31001941A
License Number StateIN

VIII. Authorized Official

Name: MRS. TYLA HUDON
Title or Position: PRESIDENT/OWNER
Credential: OTR
Phone: 317-379-1794