Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTAA01579 | KY |
NPI | 1023091279 |
---|---|
Provider Name | Mrs. Diane A Brock |
First Address | Indianapolis, IN 46227-1917 |
Second Address | Indianapolis, IN 46227-1917 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2005 |
Last Update Date | 08/07/2007 |