Healthcare Provider Details

I. General information

NPI: 1508311705
Provider Name (Legal Business Name): TRACEY LEIGH CREWS MS, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 EAST STATE BOULEVARD
FORT WAYNE IN
46815-6917
US

IV. Provider business mailing address

3500 DEPAUW BOULEVARD SUITE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 885-324-0885
  • Fax: 765-450-6664
Mailing address:
  • Phone: 317-449-4833
  • Fax: 765-450-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number014885
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201005313
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number31006496A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: