Individual
ELLEN LEIGH THEIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
1 VETERANS WAY, MEXICO, MO 65265-3379
(573) 567-8278
Mailing address
6366 HIGHWAY P, CLARK, MO 65243-3542
(660) 833-8791
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
20160005931
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20160005931
STATE OTA LICENSE
MO
Enumeration date
08/20/2021
Last updated
08/20/2021
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