Healthcare Provider Details

I. General information

NPI: 1821770900
Provider Name (Legal Business Name): SPENCER THOMAS COLLINS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15425 MANCHESTER RD STE 28
BALLWIN MO
63011-3077
US

IV. Provider business mailing address

2708 SAINT LOUIS RD APT C
JEFFERSON CITY MO
65101-4477
US

V. Phone/Fax

Practice location:
  • Phone: 636-220-6969
  • Fax:
Mailing address:
  • Phone: 314-798-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2013038749
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: