Provider Demographics
NPI:1508597634
Name:OTTO, DARYIAN MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:DARYIAN
Middle Name:MICHELLE
Last Name:OTTO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:DARYIAN
Other - Middle Name:MICHELLE
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:281 NW 90TH ST
Mailing Address - Street 2:
Mailing Address - City:SPICKARD
Mailing Address - State:MO
Mailing Address - Zip Code:64679-8304
Mailing Address - Country:US
Mailing Address - Phone:660-654-2892
Mailing Address - Fax:
Practice Address - Street 1:400 N STEWART ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MO
Practice Address - Zip Code:64673-1302
Practice Address - Country:US
Practice Address - Phone:660-748-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist