MEDICARE: MRS. JOHANNA B DOLL PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	102453	MO

General Provider Information

NPI Number	:	1477702058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHANNA B DOLL PT

Provider Business Mailing Address
First Line	:	13537 BARRETT PARKWAY DR
Second Line	:	SUITE 105
City	:	BALLWIN
State	:	MO
Zip	:	63021-5899
Country	:	US
Telephone Number	:	314-821-9126
Fax Number	:	314-821-9142

Provider Business Practice Location Address
First Line	:	2937 S BRENTWOOD BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-2713
Country	:	US
Telephone Number	:	314-961-3804
Fax Number	:	314-961-1147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	10/09/2008

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