Provider Demographics
NPI:1407996440
Name:DAVISSON, ANTOINETTE (OTR)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:DAVISSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:H
Other - Last Name:DAVISSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2601 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3061
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT8867225XP0200X
IN31002295A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000604008OtherANTHEM PROVIDER NUMBER
IN200328240Medicaid
IN815500FF6Medicare PIN