Provider Demographics
NPI:1528709524
Name:SHURTLEFF, CHARLA SALMON (COTA/L)
Entity type:Individual
Prefix:
First Name:CHARLA
Middle Name:SALMON
Last Name:SHURTLEFF
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 1:273 COVENTRY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63089-2437
Mailing Address - Country:US
Mailing Address - Phone:636-667-7028
Mailing Address - Fax:
Practice Address - Street 1:332 STABLE LN
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-5447
Practice Address - Country:US
Practice Address - Phone:636-332-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001012193224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant