Provider Demographics
NPI:1063162014
Name:SIDDLE, LAURA (MOT/R, CLC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SIDDLE
Suffix:
Gender:F
Credentials:MOT/R, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 COUNTRY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6368
Mailing Address - Country:US
Mailing Address - Phone:636-359-5540
Mailing Address - Fax:
Practice Address - Street 1:2150 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-0844
Practice Address - Country:US
Practice Address - Phone:636-946-4966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist