Provider Demographics
NPI:1588878334
Name:CUEVAS, AMELIA BONIFACIO
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:BONIFACIO
Last Name:CUEVAS
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 1:825 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-1222
Mailing Address - Country:US
Mailing Address - Phone:573-223-4812
Mailing Address - Fax:573-223-7820
Practice Address - Street 1:825 N MAIN ST
Practice Address - Street 2:CLEARWATER R-I
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1222
Practice Address - Country:US
Practice Address - Phone:573-223-4812
Practice Address - Fax:573-223-7820
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002357225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO473977528Medicaid