Provider Demographics
NPI:1568715811
Name:THOMAS, TABATHA (OT LIMITED PERMIT)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OT LIMITED PERMIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6042 PERSHING AVE
Mailing Address - Street 2:APT. A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1310
Mailing Address - Country:US
Mailing Address - Phone:731-415-1794
Mailing Address - Fax:
Practice Address - Street 1:250 S NEW FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-6716
Practice Address - Country:US
Practice Address - Phone:314-838-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2012026278OtherSTATE OF MISSOURI, MISSOURI BOARD OF HEALING ARTS