Provider Demographics
NPI:1962522458
Name:GANTNER, MICHELLE (COTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GANTNER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 LOGAN VALLEY DR.
Mailing Address - Street 2:
Mailing Address - City:ST.PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:636-379-9106
Mailing Address - Fax:
Practice Address - Street 1:250 NEW FLORISSANT ROAD SOUTH
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031
Practice Address - Country:US
Practice Address - Phone:314-830-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999137004224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant