Provider Demographics
NPI:1235273210
Name:LINE, KAREN (OTR)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:LINE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:11116 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8931
Mailing Address - Country:US
Mailing Address - Phone:260-471-0847
Mailing Address - Fax:
Practice Address - Street 1:3320 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1918
Practice Address - Country:US
Practice Address - Phone:260-483-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000090A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000205851OtherBLUE CROSS BLUE SHIELD