Provider Demographics
NPI:1629338983
Name:HARDIN, DUSTIN MONROE (PTA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:MONROE
Last Name:HARDIN
Suffix:
Gender:M
Credentials:PTA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 E STOP 11 RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9120
Mailing Address - Country:US
Mailing Address - Phone:317-884-3380
Mailing Address - Fax:317-884-3390
Practice Address - Street 1:4625 E STOP 11 RD
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9120
Practice Address - Country:US
Practice Address - Phone:317-884-3380
Practice Address - Fax:317-884-3390
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003787A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant