Provider Demographics
NPI:1982335311
Name:PIACENTINO, MICAELA
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:PIACENTINO
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 1:816 E LOREN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1724
Mailing Address - Country:US
Mailing Address - Phone:314-570-8683
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE # KMPT160
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:314-570-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer