Provider Demographics
NPI:1780126573
Name:MCDERMOTT, RACHEL ANN (PTA)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 PINE LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2316
Mailing Address - Country:US
Mailing Address - Phone:219-326-1082
Mailing Address - Fax:219-326-1413
Practice Address - Street 1:513 PINE LAKE AVE
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2316
Practice Address - Country:US
Practice Address - Phone:219-326-1082
Practice Address - Fax:219-326-1413
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN16-012191-13747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201364430OtherMEDICAID LPI