Provider Demographics
NPI:1730629189
Name:MRAZ, KOURTNEY (OTR/L)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:MRAZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2336 S 9TH ST
Mailing Address - Street 2:APT. C
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-4238
Mailing Address - Country:US
Mailing Address - Phone:815-450-0069
Mailing Address - Fax:
Practice Address - Street 1:2336 S 9TH ST
Practice Address - Street 2:APT. C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-4238
Practice Address - Country:US
Practice Address - Phone:815-450-0069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017000689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist