Healthcare Provider Details

I. General information

NPI: 1538724752
Provider Name (Legal Business Name): MARY A RADEMAKER MAT, MS ED, MS IECE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 REBA JACKSON DR
JEFFERSONVILLE IN
47130-8578
US

IV. Provider business mailing address

320 REBA JACKSON DR
JEFFERSONVILLE IN
47130-8578
US

V. Phone/Fax

Practice location:
  • Phone: 812-786-9111
  • Fax:
Mailing address:
  • Phone: 812-786-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: