Provider Demographics
NPI:1467936112
Name:OUELLETTE, TERI RAE (LSLS CERT AVED)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:RAE
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:LSLS CERT AVED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9192 WALDEMAR RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1131
Mailing Address - Country:US
Mailing Address - Phone:317-471-8560
Mailing Address - Fax:317-471-8627
Practice Address - Street 1:9192 WALDEMAR RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1131
Practice Address - Country:US
Practice Address - Phone:317-471-8560
Practice Address - Fax:317-471-8627
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1529181222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist