Healthcare Provider Details

I. General information

NPI: 1841107463
Provider Name (Legal Business Name): SKYLAR DIVINE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N KENTUCKY AVE
WEST PLAINS MO
65775-2029
US

IV. Provider business mailing address

PO BOX 137
HARTVILLE MO
65667-0137
US

V. Phone/Fax

Practice location:
  • Phone: 417-256-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2026016006
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: