=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609493469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PYRAMID REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2020
-----------------------------------------------------
Last Update Date | 06/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9165 OTIS AVE STE 101
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46216-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-3135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10225 COLVILLE LN
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46236-8302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-213-3135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | TRACY LOOPER
-----------------------------------------------------
Credential | MA, CCC-SLP
-----------------------------------------------------
Telephone | 317-213-3135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------