Provider Demographics
NPI:1144409624
Name:MITZI M. CLEARY, OTD, OTR/L, INC.
Entity Type:Organization
Organization Name:MITZI M. CLEARY, OTD, OTR/L, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITZI
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:816-383-0924
Mailing Address - Street 1:18939 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB
Mailing Address - State:MO
Mailing Address - Zip Code:64505-4058
Mailing Address - Country:US
Mailing Address - Phone:816-383-0924
Mailing Address - Fax:816-279-3094
Practice Address - Street 1:18939 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB
Practice Address - State:MO
Practice Address - Zip Code:64505-4058
Practice Address - Country:US
Practice Address - Phone:816-383-0924
Practice Address - Fax:816-279-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003000911225X00000X
KS1702329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000E880Medicare PIN