Provider Demographics
NPI:1144571779
Name:BOLEJACK, DWIGHT EUGENE (OCCUPATIONAL THERAPI)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:EUGENE
Last Name:BOLEJACK
Suffix:
Gender:M
Credentials:OCCUPATIONAL THERAPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10222 N COUNTY ROAD 1075 E
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9659
Mailing Address - Country:US
Mailing Address - Phone:317-443-6099
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-886-4677
Practice Address - Fax:812-886-4678
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002064A225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology