Provider Demographics
NPI:1073010344
Name:AHOLT, MICHAELA M
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:M
Last Name:AHOLT
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 1:7055 MEXICO RD UNIT 1601
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2344
Mailing Address - Country:US
Mailing Address - Phone:636-866-1341
Mailing Address - Fax:636-323-2155
Practice Address - Street 1:7055 MEXICO RD UNIT 1601
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2344
Practice Address - Country:US
Practice Address - Phone:636-866-1341
Practice Address - Fax:636-323-2155
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018011072225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist