Healthcare Provider Details

I. General information

NPI: 1801075502
Provider Name (Legal Business Name): KRISTEN SUZANNE GILLETTE OTR/L, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS KRISTEN SUZANNE SHELVER

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 E HAMILTON ST
KIRKSVILLE MO
63501-3904
US

IV. Provider business mailing address

1901 E HAMILTON ST
KIRKSVILLE MO
63501-3904
US

V. Phone/Fax

Practice location:
  • Phone: 660-626-1400
  • Fax: 660-665-3281
Mailing address:
  • Phone: 660-626-1400
  • Fax: 660-665-3281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2006031899
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007033623
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: