Provider Demographics
NPI:1356537138
Name:BLAINE, CHERITA R (COTA)
Entity type:Individual
Prefix:MRS
First Name:CHERITA
Middle Name:R
Last Name:BLAINE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 RADNOR RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-2149
Mailing Address - Country:US
Mailing Address - Phone:317-542-0186
Mailing Address - Fax:
Practice Address - Street 1:4415 RADNOR RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-2149
Practice Address - Country:US
Practice Address - Phone:317-542-0186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000124A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200828270AMedicaid
IN234900Medicare PIN