Provider Demographics
NPI:1609365535
Name:ANTOLIN, ALLISON LEE (MS, OTR)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:LEE
Last Name:ANTOLIN
Suffix:
Gender:F
Credentials:MS, OTR
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:LEE
Other - Last Name:NORTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD., SUITE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46238-6135
Mailing Address - Country:US
Mailing Address - Phone:317-449-4833
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:21 SOUTH PARK BLVD., SUITE 21
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8838
Practice Address - Country:US
Practice Address - Phone:317-449-2104
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002997A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1034906OtherNBCOT BOARD CERTIFICATION
IN300018235Medicaid