Provider Demographics
NPI:1932485547
Name:SAMPLE, EDITH MARCIA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:MARCIA
Last Name:SAMPLE
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 1:800 S WHITE OAK RD
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-2231
Mailing Address - Country:US
Mailing Address - Phone:918-961-1162
Mailing Address - Fax:
Practice Address - Street 1:800 S WHITE OAK RD
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2231
Practice Address - Country:US
Practice Address - Phone:417-468-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002548225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation