MEDICARE: JAIME M MATHIEU MCEVOY MSOT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	225X00000X	Occupational Therapist	2019004539	MO

General Provider Information

NPI Number	:	1316416951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAIME M MATHIEU MCEVOY MSOT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2937 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2713
Country	:	US
Telephone Number	:	314-961-3804
Fax Number	:	314-961-1147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	04/28/2022

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