Healthcare Provider Details

I. General information

NPI: 1265556245
Provider Name (Legal Business Name): RACHAEL DIANE LYNN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 CENTURY DRIVE
EDWARDSVILLE IL
62025-3772
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DRIVE STE 105
BALLWIN MO
63021-5866
US

V. Phone/Fax

Practice location:
  • Phone: 618-307-3434
  • Fax: 618-307-3435
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1170141
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number70015156
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2535
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2005010782
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: