Provider Demographics
NPI:1902355092
Name:STIRES, GINA (MSOT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:STIRES
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:STIRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSOT
Mailing Address - Street 1:5088 CHERRY PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-1804
Mailing Address - Country:US
Mailing Address - Phone:415-308-8096
Mailing Address - Fax:
Practice Address - Street 1:1000 E MONTCLAIR ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5026
Practice Address - Country:US
Practice Address - Phone:866-336-8073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032909225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation