Healthcare Provider Details

I. General information

NPI: 1508803164
Provider Name (Legal Business Name): DANIEL F REXROTH PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST
INDIANAPOLIS IN
46202-2207
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-7300
  • Fax:
Mailing address:
  • Phone: 317-962-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041914A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number20041914
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number20041914A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: