Basic Information
| Provider Information | |||||||||
| NPI: | 1508311705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREWS | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MS, OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BOULEVARD | ||||||||
| Address2: | SUITE 3070 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174494833 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Practice Location | |||||||||
| Address1: | 4422 EAST STATE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468156917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8853240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 12/26/2017 | ||||||||
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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 | 225XP0200X | 014885 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225XP0200X | 5201005313 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225XP0200X | 31006496A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1015036 | 01 | NBCOT CERTIFICATION | OTHER |