Provider Demographics
NPI:1023207719
Name:RICKARDS, DONNA WONG (MS,OTR/L)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:WONG
Last Name:RICKARDS
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12145 BRIDGETON SQ
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2616
Mailing Address - Country:US
Mailing Address - Phone:207-650-4340
Mailing Address - Fax:
Practice Address - Street 1:12145 BRIDGETON SQ
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2616
Practice Address - Country:US
Practice Address - Phone:207-650-4340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9479225X00000X
RIOT01087225X00000X
MO2009012932225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist