Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 297910 | MO |
NPI | 1023542289 |
---|---|
Provider Name | Tina Stafford |
First Address | Republic, MO 65738-1241 |
Second Address | Ozark, MO 65721-9164 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2017 |
Last Update Date | 14/04/2017 |