Healthcare Provider Details

I. General information

NPI: 1336212638
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 05/13/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6437 RUCKER RD STE D
INDIANAPOLIS IN
46220-4868
US

IV. Provider business mailing address

6437 RUCKER RD STE D
INDIANAPOLIS IN
46220-4868
US

V. Phone/Fax

Practice location:
  • Phone: 317-405-9016
  • Fax: 888-654-4116
Mailing address:
  • Phone: 317-405-9016
  • Fax: 888-654-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. CYNTHIA HOLTZ
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 317-405-9016