Provider Demographics
NPI:1770512246
Name:BENDER, MICHAEL (OT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BENDER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11469 OLIVE BLVD
Mailing Address - Street 2:#116
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7108
Mailing Address - Country:US
Mailing Address - Phone:314-291-9900
Mailing Address - Fax:314-291-9909
Practice Address - Street 1:5240 OAKLAND AVE # A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1436
Practice Address - Country:US
Practice Address - Phone:314-291-9900
Practice Address - Fax:314-291-9909
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004823225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000027007Medicare PIN