MEDICARE: REBECCA ANN REQUARTH MSOT

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	225XP0200X	Pediatric Occupational Therapist	31005435A	IN
2	225X00000X	Occupational Therapist	31005435A	IN

General Provider Information

NPI Number	:	1811236631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA ANN REQUARTH MSOT

Provider Business Mailing Address
First Line	:	3500 DEPAUW BOULEVARD
Second Line	:	SUITE 3070
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:	765-454-9759

Provider Business Practice Location Address
First Line	:	6635 EAST 21ST STREET
Second Line	:	SUITE 100, WEST BUILDING
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-2254
Country	:	US
Telephone Number	:	317-608-2824
Fax Number	:	765-454-9759

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

Provider Enumeration Date	:	02/14/2013
Last Update Date	:	04/04/2018

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Directions to “ REBECCA ANN REQUARTH MSOT” Practice Location

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