Provider Demographics
NPI:1851419071
Name:KORN, RICHARD EUGENE (OTRL)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:EUGENE
Last Name:KORN
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 N SHADELAND AVE
Mailing Address - Street 2:#207
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4809
Mailing Address - Country:US
Mailing Address - Phone:317-332-8374
Mailing Address - Fax:
Practice Address - Street 1:11623 ARBOR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2981
Practice Address - Country:US
Practice Address - Phone:866-334-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3100232A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist