Provider Demographics
NPI:1558705921
Name:STATELINE REGIONAL THERAPIST
Entity Type:Organization
Organization Name:STATELINE REGIONAL THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUNTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-259-0906
Mailing Address - Street 1:630 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COLLEGE CORNER
Mailing Address - State:IN
Mailing Address - Zip Code:47003-9308
Mailing Address - Country:US
Mailing Address - Phone:513-259-0906
Mailing Address - Fax:765-732-4112
Practice Address - Street 1:630 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:WEST COLLEGE CORNER
Practice Address - State:IN
Practice Address - Zip Code:47003-9308
Practice Address - Country:US
Practice Address - Phone:513-259-0906
Practice Address - Fax:765-732-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty