Provider Demographics
NPI:1417276205
Name:DEZELAN, LINDSAY A (OT)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:A
Last Name:DEZELAN
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 1:13431 OLD MERIDIAN ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7101
Mailing Address - Country:US
Mailing Address - Phone:317-249-2616
Mailing Address - Fax:317-249-2618
Practice Address - Street 1:13431 OLD MERIDIAN ST
Practice Address - Street 2:SUITE 225
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7101
Practice Address - Country:US
Practice Address - Phone:317-249-2616
Practice Address - Fax:317-249-2618
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004976A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000667631OtherANTHEM PROVIDER NUMBER
IN200986800Medicaid
INP00856478Medicare PIN
INM400067180Medicare PIN
INM400019655Medicare PIN