NPIMap

Organization Active NPI

Lifetime Redesign OT, PLLC

  • Geriatric Medicine (Family Medicine) Physician
  • Saint Louis, MO
National Provider Identifier
1013666403
Registry record updated May 29, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
Legal business name
LIFETIME REDESIGN OT, PLLC
Practice address
12395 Olive Blvd Ste 200
Saint Louis, MO 63141-5465
Phone
(646) 319-9017
NPI assigned
Mar 22, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 29, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joseph MitchellNPI 1952669152
Title
Authorized Official
Phone
(270) 993-4789

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X
Geriatric Medicine (Family Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207QG0300X Primary

Addresses

Primary practice location

12395 Olive Blvd Ste 200
Saint Louis, MO 63141-5465

Mailing address

1449 S Michigan Ave Ste 13138
Chicago, IL 60605-2810
Phone (646) 319-9017

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY, MO, NC3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20221012000608 NY Part B Supplier - Clinic/Group Practice 6901272244 Receives reassigned benefits from 9 practitioners
Practice locations: Albany, NY
O20250625002485 MO Part B Supplier - Clinic/Group Practice 6901272244 Receives reassigned benefits from 2 practitioners
Practice locations: Saint Louis, MO
O20251113000155 NC Part B Supplier - Clinic/Group Practice 6901272244 Receives reassigned benefits from 1 practitioner
Practice locations: Apex, NC

National Provider Directory

National Provider Directory

Locations

12395 Olive Blvd
Saint Louis, MO 63141

80 State St
Albany, NY 12207
Phone (415) 742-8411

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1647907200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1748476800000",
    "number": "1013666403",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1449 S MICHIGAN AVE STE 13138",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606052810",
            "telephone_number": "646-319-9017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12395 OLIVE BLVD STE 200",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631415465",
            "telephone_number": "646-319-9017"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFETIME REDESIGN OT, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-03-22",
        "last_updated": "2025-05-29",
        "certification_date": "2025-05-29",
        "status": "A",
        "authorized_official_last_name": "MITCHELL",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "270-993-4789"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207QG0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.