Provider Demographics
NPI:1992838098
Name:NEWBERRY, MICHELLE (OTA-L)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NEWBERRY
Suffix:
Gender:F
Credentials:OTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11922 HOLLY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1348
Mailing Address - Country:US
Mailing Address - Phone:314-705-2646
Mailing Address - Fax:
Practice Address - Street 1:250 S NEW FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-6716
Practice Address - Country:US
Practice Address - Phone:314-830-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999140473224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant