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General NPI Number Information
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NPI Number | 1477389690
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Entity Type | Individual
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Provider Name | TESSA MARIE PENICK
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Gender | Female
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Dates
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Enumeration Date | 09/12/2024
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 610 VINELAND SCHOOL RD
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City | DE SOTO
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State | MO
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Zip | 63020-2561
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Country | US
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Telephone | 636-586-1000
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Fax | 636-586-1009
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Provider Business Mailing Address
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Address Line | 805 WRANGLER RDG APT 103
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City | FESTUS
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State | MO
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Zip | 63028-2684
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Country | US
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Telephone | 314-570-9887
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 2021011245
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License Number State | MO
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