Provider Demographics
NPI:1114182383
Name:STINE, TISHA (OTR)
Entity type:Individual
Prefix:MR
First Name:TISHA
Middle Name:
Last Name:STINE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 E 300 S
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-9741
Mailing Address - Country:US
Mailing Address - Phone:317-468-0727
Mailing Address - Fax:
Practice Address - Street 1:745 N SWOPE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1332
Practice Address - Country:US
Practice Address - Phone:317-462-9221
Practice Address - Fax:317-462-5076
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-27
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002669A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist