Healthcare Provider Details

I. General information

NPI: 1689146672
Provider Name (Legal Business Name): GORDON BERNERD TSUBIRA OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 S PATTERSON AVE
JOPLIN MO
64804-2464
US

IV. Provider business mailing address

2321 S PATTERSON AVE
JOPLIN MO
64804-2464
US

V. Phone/Fax

Practice location:
  • Phone: 417-551-3806
  • Fax:
Mailing address:
  • Phone: 417-551-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2019045933
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: