Healthcare Provider Details

I. General information

NPI: 1013666403
Provider Name (Legal Business Name): LIFETIME REDESIGN OT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 OLIVE BLVD STE 200
SAINT LOUIS MO
63141-5465
US

IV. Provider business mailing address

1449 S MICHIGAN AVE STE 13138
CHICAGO IL
60605-2810
US

V. Phone/Fax

Practice location:
  • Phone: 646-319-9017
  • Fax:
Mailing address:
  • Phone: 646-319-9017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH MITCHELL
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 270-993-4789