Provider Demographics
NPI:1104080399
Name:YOUNG, MARIO ANDROLIS (COTA)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ANDROLIS
Last Name:YOUNG
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 WINTHROP AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1972
Mailing Address - Country:US
Mailing Address - Phone:317-283-7742
Mailing Address - Fax:
Practice Address - Street 1:1001 N GRANT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1944
Practice Address - Country:US
Practice Address - Phone:765-482-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000023A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant