Provider Demographics
NPI:1386677342
Name:TUBERGEN, REBECCA (OT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:TUBERGEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PENNSYLVANIA PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1393
Mailing Address - Country:US
Mailing Address - Phone:317-817-1200
Mailing Address - Fax:317-817-1220
Practice Address - Street 1:201 PENNSYLVANIA PKWY
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1393
Practice Address - Country:US
Practice Address - Phone:317-817-1200
Practice Address - Fax:317-817-1220
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002140225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200396460Medicaid
IN200396460Medicaid