Healthcare Provider Details

I. General information

NPI: 1700527744
Provider Name (Legal Business Name): MELISSA TERESA BRINK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 PARMA DR
BALLWIN MO
63021-6511
US

IV. Provider business mailing address

917 PARMA DR
BALLWIN MO
63021-6511
US

V. Phone/Fax

Practice location:
  • Phone: 314-440-9090
  • Fax:
Mailing address:
  • Phone: 314-440-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2014024344
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: