Healthcare Provider Details

I. General information

NPI: 1508821018
Provider Name (Legal Business Name): TANIE S SQUIER O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12124 GEIST COVE DR
INDIANAPOLIS IN
46236-9192
US

IV. Provider business mailing address

12124 GEIST COVE DR
INDIANAPOLIS IN
46236-9192
US

V. Phone/Fax

Practice location:
  • Phone: 317-627-1832
  • Fax: 317-826-2755
Mailing address:
  • Phone: 317-627-1832
  • Fax: 317-826-2755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number31000552A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: