Provider Demographics
NPI:1063615193
Name:GAULT, DANETTE J
Entity type:Individual
Prefix:
First Name:DANETTE
Middle Name:J
Last Name:GAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HIGHWAY F
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:MO
Mailing Address - Zip Code:64831-9813
Mailing Address - Country:US
Mailing Address - Phone:918-314-1182
Mailing Address - Fax:
Practice Address - Street 1:400 W LYON DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-9194
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
MO005022224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant