MEDICARE: THERESA ANN DORE MOTR/L

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	225XP0200X	Pediatric Occupational Therapist	2007020122	MO

General Provider Information

NPI Number	:	1760679955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA ANN DORE MOTR/L

Provider Business Mailing Address
First Line	:	5041 WATERMAN BLVD
Second Line	:	APT. 108
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1164
Country	:	US
Telephone Number	:	630-624-7942
Fax Number	:

Provider Business Practice Location Address
First Line	:	5041 WATERMAN BLVD
Second Line	:	APT. 108
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1164
Country	:	US
Telephone Number	:	630-624-7942
Fax Number	:

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

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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