Provider Demographics
NPI:1407951791
Name:CLEARY, MITZI MICHELLE (OTD, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:MICHELLE
Last Name:CLEARY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:MRS
Other - First Name:MITZI
Other - Middle Name:MICHELLE
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
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:816-279-3020
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:816-279-3020
Practice Address - Fax:816-279-3094
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003000911225X00000X
KS17-02329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO711037536OtherEMPLOYMENT IDENTIFICATION NUMBER
MO711037536OtherEMPLOYMENT IDENTIFICATION NUMBER