Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 32001082A | IN |
NPI | 1013176742 |
---|---|
Provider Name | Ms. Mary Josephine Smith |
First Address | Elkhart, IN 46516-4002 |
Second Address | Goshen, IN 46528-5010 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2008 |
Last Update Date | 06/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32001082A | STATE LICENSE (01) | IN |