Healthcare Provider Details

I. General information

NPI: 1871599977
Provider Name (Legal Business Name): DANIEL WILLIAM CHETTLEBURGH OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 MIAMI CIR
SOUTH BEND IN
46614-6480
US

IV. Provider business mailing address

6450 MIAMI CIR
SOUTH BEND IN
46614-6480
US

V. Phone/Fax

Practice location:
  • Phone: 574-231-1389
  • Fax: 574-231-1502
Mailing address:
  • Phone: 574-231-1389
  • Fax: 574-231-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000080A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: