Provider Demographics
NPI:1063815389
Name:ALLEN, LAURIE SUSAN (OTR CHT)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:SUSAN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2605 E CREEKS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8368
Mailing Address - Country:US
Mailing Address - Phone:812-333-2663
Mailing Address - Fax:812-349-9206
Practice Address - Street 1:583 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5515
Practice Address - Country:US
Practice Address - Phone:812-333-2663
Practice Address - Fax:812-349-9206
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000726A225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1063815389Medicare NSC