Provider Demographics
NPI:1083132690
Name:NURSE, SALLY MARIE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:MARIE
Last Name:NURSE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-454-9759
Practice Address - Street 1:6635 EAST 21ST STREET
Practice Address - Street 2:SUITE 100 WEST BUILDING
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-2254
Practice Address - Country:US
Practice Address - Phone:317-608-2824
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2017-09-04
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
IN31000786A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics