Healthcare Provider Details

I. General information

NPI: 1184688699
Provider Name (Legal Business Name): ELIZABETH MARIE OBRIEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MARIE TRAHIN PTA

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5949 W RAYMOND ST
INDIANAPOLIS IN
46241-4348
US

IV. Provider business mailing address

5949 W RAYMOND ST
INDIANAPOLIS IN
46241-4348
US

V. Phone/Fax

Practice location:
  • Phone: 317-390-5575
  • Fax: 317-486-2189
Mailing address:
  • Phone: 317-390-5575
  • Fax: 317-486-2189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06003162A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: