Provider Demographics
NPI:1528539046
Name:SIMON, MARY ANN ELIZABETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:ELIZABETH
Last Name:SIMON
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 1:2204 SILVER LINDEN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4404
Mailing Address - Country:US
Mailing Address - Phone:314-606-9904
Mailing Address - Fax:
Practice Address - Street 1:280 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4510
Practice Address - Country:US
Practice Address - Phone:636-327-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018025725224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant