Provider Demographics
NPI:1396227286
Name:BUCKLEY, MICHELLE PAYGE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:PAYGE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W SUNDALE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-2732
Mailing Address - Country:US
Mailing Address - Phone:660-351-3185
Mailing Address - Fax:
Practice Address - Street 1:1300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-2728
Practice Address - Country:US
Practice Address - Phone:660-351-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028150224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant