MEDICARE: JANINE M GIACONIA MOT

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	390200000X	Student in an Organized Health Care Education/Training Program
2	225X00000X	Occupational Therapist		MO

General Provider Information

NPI Number	:	1750807269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANINE M GIACONIA MOT

Provider Business Mailing Address
First Line	:	1034 WINTER PARK DR
Second Line	:
City	:	FENTON
State	:	MO
Zip	:	63026-5689
Country	:	US
Telephone Number	:	631-626-0499
Fax Number	:

Provider Business Practice Location Address
First Line	:	1034 WINTER PARK DR
Second Line	:
City	:	FENTON
State	:	MO
Zip	:	63026-5689
Country	:	US
Telephone Number	:	631-626-0499
Fax Number	:

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

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	11/26/2018

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