Provider Demographics
NPI:1114317765
Name:RETHLAKE, DEVIN SUSANN
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:SUSANN
Last Name:RETHLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 W KECK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-9558
Mailing Address - Country:US
Mailing Address - Phone:260-610-4527
Mailing Address - Fax:
Practice Address - Street 1:900 PROVIDENT DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3252
Practice Address - Country:US
Practice Address - Phone:574-371-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002669A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant