Provider Demographics
NPI:1558434696
Name:NIEDERHAUSER, LAURIE (PT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:NIEDERHAUSER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11699 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2805
Mailing Address - Country:US
Mailing Address - Phone:317-507-2470
Mailing Address - Fax:317-284-1559
Practice Address - Street 1:11699 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2805
Practice Address - Country:US
Practice Address - Phone:317-507-2470
Practice Address - Fax:317-284-1559
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005656A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200651560Medicaid