Provider Demographics
NPI:1316272214
Name:WHITE, TINA MARIE (COTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12712 JUSTICE CROSSING
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037
Mailing Address - Country:US
Mailing Address - Phone:317-776-1679
Mailing Address - Fax:
Practice Address - Street 1:1345 NORTH MADISON AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-1215
Practice Address - Country:US
Practice Address - Phone:765-644-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001003A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant