Healthcare Provider Details

I. General information

NPI: 1245447291
Provider Name (Legal Business Name): REGINA DANYEL DICRISTOFARO MSOTR,L
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

802 E US HIGHWAY 20
MICHIGAN CITY IN
46360-7424
US

IV. Provider business mailing address

316 N CALUMET AVE
MICHIGAN CITY IN
46360-5017
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-7251
  • Fax:
Mailing address:
  • Phone: 219-871-0527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004241A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: