Basic Information
| Provider Information | |||||||||
| NPI: | 1639381551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VETETO | ||||||||
| FirstName: | KARRIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLAGRAVE | ||||||||
| OtherFirstName: | KARRIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7726 CASTLE RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 KINGSWAY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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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 | 31004285A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 103K00000X | 1-13-14734 | IN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 100462120 | 05 | IN | MEDICAID |