MEDICARE: KRISTEN MACY

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	31004953A	IN

General Provider Information

NPI Number	:	1669939864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MACY

Provider Business Mailing Address
First Line	:	3384 RIDERS TRL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-0005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 E RUDISILL BLVD STE 301
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1756
Country	:	US
Telephone Number	:	260-348-9887
Fax Number	:

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

Provider Enumeration Date	:	02/23/2019
Last Update Date	:	02/23/2019

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Directions to “ KRISTEN MACY ” Practice Location

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