Provider Demographics
NPI: | 1811236631 |
---|---|
Name: | REQUARTH, REBECCA ANN (MSOT) |
Entity Type: | Individual |
Prefix: | |
First Name: | REBECCA |
Middle Name: | ANN |
Last Name: | REQUARTH |
Suffix: | |
Gender: | F |
Credentials: | MSOT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3500 DEPAUW BOULEVARD |
Mailing Address - Street 2: | SUITE 3070 |
Mailing Address - City: | INDIANAPOLIS |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46268-6135 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 855-324-0885 |
Mailing Address - Fax: | 765-454-9759 |
Practice Address - Street 1: | 6635 EAST 21ST STREET |
Practice Address - Street 2: | SUITE 100, WEST BUILDING |
Practice Address - City: | INDIANAPOLIS |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46219-2254 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-608-2824 |
Practice Address - Fax: | 765-454-9759 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-02-14 |
Last Update Date: | 2018-04-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 31005435A | 225XP0200X, 225X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | |
No | 225XP0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |