Provider Demographics
NPI:1306679642
Name:WHITENER, GINA LOUISE (COTA/L)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:LOUISE
Last Name:WHITENER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 PRAIRIE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HERCULANEUM
Mailing Address - State:MO
Mailing Address - Zip Code:63048-1640
Mailing Address - Country:US
Mailing Address - Phone:314-852-1487
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEVELY
Practice Address - State:MO
Practice Address - Zip Code:63070-3311
Practice Address - Country:US
Practice Address - Phone:636-479-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004641224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty