Provider Demographics
NPI:1073180816
Name:RYAN, LAURA (COTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RYAN
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 1:220 CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:GRAY SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:63039-1122
Mailing Address - Country:US
Mailing Address - Phone:636-667-1397
Mailing Address - Fax:
Practice Address - Street 1:1800 WEIN ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1601
Practice Address - Country:US
Practice Address - Phone:573-486-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021029637224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant