Provider Demographics
NPI:1558488510
Name:BEAVER, ANGELA (OTR)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:BEAVER
Suffix:
Gender:
Credentials:OTR
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1712 DUART CT
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:IN
Mailing Address - Zip Code:46774-2214
Mailing Address - Country:US
Mailing Address - Phone:317-460-5146
Mailing Address - Fax:
Practice Address - Street 1:1100 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2303
Practice Address - Country:US
Practice Address - Phone:260-724-2145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004126A286500000X, 314000000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No286500000XHospitalsMilitary Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility