Provider Demographics
NPI:1295809812
Name:PENNER, MARCI (OT)
Entity type:Individual
Prefix:
First Name:MARCI
Middle Name:
Last Name:PENNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10580 DEEPWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9446
Mailing Address - Country:US
Mailing Address - Phone:317-441-6765
Mailing Address - Fax:
Practice Address - Street 1:10580 DEEPWOOD TRL
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-9446
Practice Address - Country:US
Practice Address - Phone:317-441-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000769A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200651600Medicaid