Provider Demographics
NPI:1831313030
Name:ARNOLD, MARY TERESE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TERESE
Last Name:ARNOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:TERRI
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:661 N MEADOW LARK LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-2731
Mailing Address - Country:US
Mailing Address - Phone:812-334-3540
Mailing Address - Fax:
Practice Address - Street 1:661 N MEADOW LARK LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-2731
Practice Address - Country:US
Practice Address - Phone:812-327-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001121A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200612120Medicaid
IN200710840AMedicaid