Provider Demographics
NPI:1114323656
Name:NORTHCUTT, DANIEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:NORTHCUTT
Suffix:
Gender:M
Credentials: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:PO BOX 504469
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4469
Mailing Address - Country:US
Mailing Address - Phone:800-677-1238
Mailing Address - Fax:
Practice Address - Street 1:1700 WHITE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-4349
Practice Address - Country:US
Practice Address - Phone:618-246-6763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003358225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist