Provider Demographics
NPI:1861579781
Name:KOHNEN, MARISA (OTR)
Entity type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:
Last Name:KOHNEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3252 ATLANTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5150
Mailing Address - Country:US
Mailing Address - Phone:219-762-9373
Mailing Address - Fax:219-983-9681
Practice Address - Street 1:1120 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3286
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:219-983-9681
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003944A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000387925OtherANTHEM PROVIDER PIN