Provider Demographics
NPI:1710657234
Name:BOOMERSHINE, KATHRYN ANN (OTD, OTR)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:BOOMERSHINE
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:909 SAGAMORE PKWY W STE 917
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1443
Practice Address - Country:US
Practice Address - Phone:765-463-0710
Practice Address - Fax:765-463-0711
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006949A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist