1144409624 NPI number — MITZI M. CLEARY, OTD, OTR/L, INC.

Table of content: (NPI 1144409624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144409624 NPI number — MITZI M. CLEARY, OTD, OTR/L, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MITZI M. CLEARY, OTD, OTR/L, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144409624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18939 EVERGREEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNTRY CLUB
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64505-4058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-383-0924
Provider Business Mailing Address Fax Number:
816-279-3094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18939 EVERGREEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNTRY CLUB
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64505-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-383-0924
Provider Business Practice Location Address Fax Number:
816-279-3094
Provider Enumeration Date:
10/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLEARY
Authorized Official First Name:
MITZI
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
816-383-0924

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  2003000911 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 1702329 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com