Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 2010030858 | MO |
NPI | 1063962777 |
---|---|
Provider Name | Samantha Lee |
First Address | Farmington, MO 63640-2930 |
Second Address | Farmington, MO 63640-2427 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2016 |
Last Update Date | 05/10/2016 |