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NPI Code Detail

MEDICARE: AJA BETHANY OTR

MEDICARE: AJA BETHANY OTR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist2006003768MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12006003768OTHERMOSTATE LICENSE

General Provider Information

NPI Number : 1073889739
Entity Type Code : Individual
Provider Name (Legal Business Name) : AJA BETHANY OTR
Provider Business Mailing Address
First Line : 5368 SUNTRAIL DR
Second Line :
City : BLACK JACK
State : MO
Zip : 63033-4425
Country : US
Telephone Number : 314-283-6955
Fax Number :
Provider Business Practice Location Address
First Line : 10600 LEWIS AND CLARK BLVD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63136-6005
Country : US
Telephone Number : 314-283-6955
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/27/2012
Last Update Date : 12/11/2025

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