Provider Demographics
NPI:1114589660
Name:WINGBERMUEHLE, ELYSE NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:NICOLE
Last Name:WINGBERMUEHLE
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 1:1505 PROSPECTOR TRL
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4925
Mailing Address - Country:US
Mailing Address - Phone:573-590-0237
Mailing Address - Fax:
Practice Address - Street 1:1393 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2355
Practice Address - Country:US
Practice Address - Phone:636-326-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010031848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist