Healthcare Provider Details

I. General information

NPI: 1710195573
Provider Name (Legal Business Name): SARA THACKER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3077 E 98TH ST SUITE 265
INDIANAPOLIS IN
46280-2940
US

IV. Provider business mailing address

3854 W FAIRVIEW RD
GREENWOOD IN
46142-8522
US

V. Phone/Fax

Practice location:
  • Phone: 317-569-1170
  • Fax:
Mailing address:
  • Phone: 317-345-6062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002816A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: