Provider Demographics
NPI:1356567366
Name:PRADA, ANGELA (OTR)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:PRADA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N 11TH ST
Mailing Address - Street 2:MEDICAID DEPARTMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-1015
Mailing Address - Country:US
Mailing Address - Phone:314-345-2535
Mailing Address - Fax:314-345-2653
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:MEDICAID DEPARTMENT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-345-2535
Practice Address - Fax:314-345-2653
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005074225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist