Provider Demographics
NPI:1760253595
Name:KOETTERS, MACY MARIE
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:MARIE
Last Name:KOETTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 LAWRENCE CT
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-2218
Mailing Address - Country:US
Mailing Address - Phone:913-660-4356
Mailing Address - Fax:
Practice Address - Street 1:6264 LEWIS DR STE 100
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-3603
Practice Address - Country:US
Practice Address - Phone:816-587-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024001149225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist