Provider Demographics
NPI:1255494514
Name:NIETO, IDA INEZ (OTR)
Entity type:Individual
Prefix:MS
First Name:IDA
Middle Name:INEZ
Last Name:NIETO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13673 S 1050 E
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:IN
Mailing Address - Zip Code:46919-9227
Mailing Address - Country:US
Mailing Address - Phone:765-243-1042
Mailing Address - Fax:765-395-3249
Practice Address - Street 1:13673 S 1050 E
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:IN
Practice Address - Zip Code:46919-9227
Practice Address - Country:US
Practice Address - Phone:765-243-1042
Practice Address - Fax:765-395-3249
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000620A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist