Healthcare Provider Details

I. General information

NPI: 1225861727
Provider Name (Legal Business Name): EMMA ROSE SPOTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 DECATUR BLVD STE A
INDIANAPOLIS IN
46241-7511
US

IV. Provider business mailing address

10341 SUGAR RIDGE WAY
INDIANAPOLIS IN
46239-9763
US

V. Phone/Fax

Practice location:
  • Phone: 317-856-5201
  • Fax:
Mailing address:
  • Phone: 317-381-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-161657
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: