Provider Demographics
NPI:1366771479
Name:MICHIANA THERAPY NETWORK
Entity type:Organization
Organization Name:MICHIANA THERAPY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GANGLUFF
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:574-339-5959
Mailing Address - Street 1:51738 SAGECREST DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6887
Mailing Address - Country:US
Mailing Address - Phone:574-339-5959
Mailing Address - Fax:
Practice Address - Street 1:51738 SAGECREST DR
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-6887
Practice Address - Country:US
Practice Address - Phone:574-339-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006025A225100000X
IN31000509A225X00000X
IN01101056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty