Provider Demographics
NPI:1114355948
Name:EDWARDS, KATIE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-2154
Mailing Address - Fax:812-353-5228
Practice Address - Street 1:2605 E CREEKS EDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8368
Practice Address - Country:US
Practice Address - Phone:812-353-3343
Practice Address - Fax:812-353-3346
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005151A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist