Provider Demographics
NPI:1376501684
Name:MYCANKA, KAREN (OTR CHT CLT)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:
Last Name:MYCANKA
Suffix:
Gender:F
Credentials:OTR CHT CLT
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:LELITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 RAINBOW BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024
Mailing Address - Country:US
Mailing Address - Phone:816-629-2700
Mailing Address - Fax:816-629-2723
Practice Address - Street 1:1700 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1182
Practice Address - Country:US
Practice Address - Phone:816-629-2700
Practice Address - Fax:816-629-2723
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000014174400000X, 225X00000X
MO9811000110225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No174400000XOther Service ProvidersSpecialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20217047OtherBCBS
MOMA1009006Medicare PIN