Healthcare Provider Details

I. General information

NPI: 1811150287
Provider Name (Legal Business Name): KELLY SUSAN WUNDERLY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5226 E 82ND ST
INDIANAPOLIS IN
46250-1628
US

IV. Provider business mailing address

8158 BIRCHFIELD DR
INDIANAPOLIS IN
46268-2895
US

V. Phone/Fax

Practice location:
  • Phone: 317-842-6668
  • Fax: 317-578-4113
Mailing address:
  • Phone: 317-709-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31003781A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: