Basic Information
| Provider Information | |||||||||
| NPI: | 1427212356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSOTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROSHEARS | ||||||||
| OtherFirstName: | TAMMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSOTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | SUITE 2313 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023099800 | ||||||||
| FaxNumber: | 5023099797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | KY-R3839 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000000972248 | 01 | KY | ANTHEM BCBS | OTHER | 236445 | 01 | NATIONAL BOARD FOR CERTIFICATION N OCCUPATIONAL THERAPY INC.. | OTHER | 7100369700 | 05 | KY | MEDICAID | 132092 | 01 | KY | LICENSE | OTHER | 31004543A | 01 | IN | INDIANA PROFESSIONAL LICENSING AGENCY FOR OCCUPATIONAL THERAPY | OTHER |