Healthcare Provider Details

I. General information

NPI: 1982908836
Provider Name (Legal Business Name): MANDISA PETTIFORD OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17134 BEL RAY PL
BELTON MO
64012-5331
US

IV. Provider business mailing address

17134 BEL RAY PL
BELTON MO
64012-5331
US

V. Phone/Fax

Practice location:
  • Phone: 816-318-0436
  • Fax: 816-318-0437
Mailing address:
  • Phone: 816-318-0436
  • Fax: 816-318-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2011006042
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: