Healthcare Provider Details

I. General information

NPI: 1528024130
Provider Name (Legal Business Name): ANNA MARIE SEYMOUR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ANNA MARIE MCCLURE PTA

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 EAST AIRLINE DR
EAST ALTON IL
62024-2031
US

IV. Provider business mailing address

935 EAST AIRLINE DR
EAST ALTON IL
62024-2031
US

V. Phone/Fax

Practice location:
  • Phone: 618-258-9093
  • Fax: 618-258-9097
Mailing address:
  • Phone: 618-258-9093
  • Fax: 618-258-9097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: