Provider Demographics
NPI:1669069035
Name:ADDISON, EMMA
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:ADDISON
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 1:236 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2411
Mailing Address - Country:US
Mailing Address - Phone:314-479-6970
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-7476
Practice Address - Country:US
Practice Address - Phone:314-479-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020016902225X00000X
TX121133225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist