Provider Demographics
NPI:1114359957
Name:KOSTOPOULOS, JOANNA D (OTR/L)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:D
Last Name:KOSTOPOULOS
Suffix:
Gender:F
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 1:5603 WATERMAN BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1885
Mailing Address - Country:US
Mailing Address - Phone:914-433-9823
Mailing Address - Fax:
Practice Address - Street 1:3501 DUNN RD STE 108
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6762
Practice Address - Country:US
Practice Address - Phone:314-972-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-03
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011026241225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist