Provider Demographics
NPI:1114044104
Name:RASMUSSEN, GENA K (MOTR L)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:K
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:MOTR L
Other - Prefix:
Other - First Name:GENA
Other - Middle Name:K
Other - Last Name:HIATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MOTR
Mailing Address - Street 1:1132 ELMONT RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-1039
Mailing Address - Country:US
Mailing Address - Phone:573-468-5174
Mailing Address - Fax:573-468-5196
Practice Address - Street 1:1132 ELMONT RD
Practice Address - Street 2:SULLIVAN CONSOLIDATED DISTRICT NO 2
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1039
Practice Address - Country:US
Practice Address - Phone:573-468-5174
Practice Address - Fax:573-468-5196
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006026901225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO477590004Medicaid