Provider Demographics
NPI:1457079857
Name:LOUISE, MABLE-GENE (LMT)
Entity Type:Individual
Prefix:
First Name:MABLE-GENE
Middle Name:
Last Name:LOUISE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-3736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5111 N BEND DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1753
Practice Address - Country:US
Practice Address - Phone:260-436-8807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X, 253Z00000X, 376K00000X
INMT22107337225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No253Z00000XAgenciesIn Home Supportive Care
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN450230-06OtherBCTMB
INLCEU0002762OtherCERTIFICATIONS BCTMB
INMT22107337OtherIN STATE LICENSE