Basic Information
| Provider Information | |||||||||
| NPI: | 1235273210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINE | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLEY | ||||||||
| OtherFirstName: | KAREN | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11116 WILLOW CREEK DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468458931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604710847 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3320 N CLINTON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468051918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604832100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31000090A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0000000205851 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER |