Basic Information
| Provider Information | |||||||||
| NPI: | 1447645874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIBEAU | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | KIMBERLEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUELLER | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | COTA/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7513 W 128TH LN | ||||||||
| Address2: | |||||||||
| City: | CEDAR LAKE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463038882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082966908 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2906 HIGHWAY AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463221631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195138311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 32002807A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.