Provider Demographics
NPI:1386315265
Name:BOUSHEY, LOREN NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:NICOLE
Last Name:BOUSHEY
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 1:850 COUNTRY MANOR LN
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6651
Mailing Address - Country:US
Mailing Address - Phone:314-434-5900
Mailing Address - Fax:
Practice Address - Street 1:850 COUNTRY MANOR LN
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6651
Practice Address - Country:US
Practice Address - Phone:314-434-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021012493224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant