Healthcare Provider Details

I. General information

NPI: 1710657234
Provider Name (Legal Business Name): KATHRYN ANN BOOMERSHINE OTD, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SAGAMORE PKWY W STE 917
WEST LAFAYETTE IN
47906-1443
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-0710
  • Fax: 765-463-0711
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31006949A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: