Healthcare Provider Details

I. General information

NPI: 1003900176
Provider Name (Legal Business Name): LUISA DIEZ ROT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E 84TH DR
MERRILLVILLE IN
46410-6484
US

IV. Provider business mailing address

399 E 84TH DR
MERRILLVILLE IN
46410-6484
US

V. Phone/Fax

Practice location:
  • Phone: 219-756-7246
  • Fax: 219-736-5856
Mailing address:
  • Phone: 219-756-7246
  • Fax: 219-736-5856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31001828A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: