Healthcare Provider Details

I. General information

NPI: 1669696068
Provider Name (Legal Business Name): SAMUELA KALLOGJERI OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N 11TH ST
SAINT LOUIS MO
63101-1015
US

IV. Provider business mailing address

5015 NOTTINGHAM AVE
SAINT LOUIS MO
63109-2962
US

V. Phone/Fax

Practice location:
  • Phone: 314-771-3312
  • Fax:
Mailing address:
  • Phone: 314-646-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2004019146
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: