Healthcare Provider Details

I. General information

NPI: 1073889739
Provider Name (Legal Business Name): AJA BETHANY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 LEWIS AND CLARK BLVD
SAINT LOUIS MO
63136-6005
US

IV. Provider business mailing address

5368 SUNTRAIL DR
BLACK JACK MO
63033-4425
US

V. Phone/Fax

Practice location:
  • Phone: 314-283-6955
  • Fax:
Mailing address:
  • Phone: 314-283-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2006003768
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: