Provider Demographics
NPI:1386828457
Name:QUACO, SHARON LEE (OT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LEE
Last Name:QUACO
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 1:22242 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9261
Mailing Address - Country:US
Mailing Address - Phone:574-299-0403
Mailing Address - Fax:
Practice Address - Street 1:430 WEST CLEVELAND ROAD
Practice Address - Street 2:APT.B23
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-243-9640
Practice Address - Fax:574-243-9640
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002026A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN253050Medicare PIN