MEDICARE: MRS. MARIE K GAGNE OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	31003188A	IN

General Provider Information

NPI Number	:	1184636607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIE K GAGNE OTR

Provider Business Mailing Address
First Line	:	5443 ASHURST ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4855
Country	:	US
Telephone Number	:	317-446-9046
Fax Number	:	317-722-0613

Provider Business Practice Location Address
First Line	:	5443 ASHURST ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4855
Country	:	US
Telephone Number	:	317-446-9046
Fax Number	:	317-722-0613

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	06/30/2008

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