Healthcare Provider Details

I. General information

NPI: 1255006110
Provider Name (Legal Business Name): AMY MERRITT OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 BIG CREEK DR
BYRNES MILL MO
63051-3315
US

IV. Provider business mailing address

6801 BIG CREEK DR
BYRNES MILL MO
63051-3315
US

V. Phone/Fax

Practice location:
  • Phone: 314-712-2103
  • Fax:
Mailing address:
  • Phone: 314-712-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2018045000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: