Provider Demographics
NPI:1588008353
Name:ELMENDORF, GINA MARIE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:ELMENDORF
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 DALTON CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3495
Practice Address - Country:US
Practice Address - Phone:636-240-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012028513225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics