Healthcare Provider Details

I. General information

NPI: 1871791921
Provider Name (Legal Business Name): MARYJANE AMAD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 SOLLEY DR
BALLWIN MO
63021-5248
US

IV. Provider business mailing address

7112 CADDIE WAY LN
SAINT LOUIS MO
63129-5266
US

V. Phone/Fax

Practice location:
  • Phone: 636-391-0666
  • Fax:
Mailing address:
  • Phone: 314-846-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number116501
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: