Provider Demographics
NPI:1952845406
Name:PEDIATRIC THERAPY OF INDIANA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:317-379-1794
Mailing Address - Street 1:10653 KESTREL CT
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-7537
Mailing Address - Country:US
Mailing Address - Phone:317-379-1794
Mailing Address - Fax:317-770-0535
Practice Address - Street 1:9000 S COUNTY ROAD 800 W
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:IN
Practice Address - Zip Code:47334-9420
Practice Address - Country:US
Practice Address - Phone:317-379-1794
Practice Address - Fax:317-770-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001941A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation