Provider Demographics
NPI:1801158399
Name:MEARS, KRISTEN (OT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MEARS
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2600 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3055
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:766-448-7615
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005167A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201073140Medicaid
IN000000772562OtherANTHEM PROVIDER NUMBER
INP01121379Medicare PIN
IN000000772562OtherANTHEM PROVIDER NUMBER