Provider Demographics
NPI:1861669152
Name:PENNYCUFF, DIANE BETH (OT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:BETH
Last Name:PENNYCUFF
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 S STATE ROAD 135
Practice Address - Street 2:SUITE C
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1443
Practice Address - Country:US
Practice Address - Phone:317-865-1110
Practice Address - Fax:317-865-0221
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001630A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist