=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629954540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAIJA SCURLOCK RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2025
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 N BROADWAY ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46140-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-462-9211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 E MAIN ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46140-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-750-3190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-25-410738
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------