Provider Demographics
NPI:1306964333
Name:SHILLITO, LAURA L (OT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:SHILLITO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:SOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:403 WAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3942
Mailing Address - Country:US
Mailing Address - Phone:314-394-1423
Mailing Address - Fax:
Practice Address - Street 1:777 S NEW BALLAS RD STE 218E
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-991-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000779225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist