Healthcare Provider Details

I. General information

NPI: 1588573638
Provider Name (Legal Business Name): SAMANTHA R STROUP COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 FORD HILL LN
BOURBON MO
65441-8236
US

IV. Provider business mailing address

54 FORD HILL LN
BOURBON MO
65441-8236
US

V. Phone/Fax

Practice location:
  • Phone: 314-314-4387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2021047570
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: