Healthcare Provider Details

I. General information

NPI: 1073845012
Provider Name (Legal Business Name): LAURA ANN EDMUNDSON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 N OUTER 40 RD SUITE 202
CHESTERFIELD MO
63005-1364
US

IV. Provider business mailing address

17300 N OUTER 40 RD SUITE 202
CHESTERFIELD MO
63005-1364
US

V. Phone/Fax

Practice location:
  • Phone: 636-728-1777
  • Fax: 636-728-1793
Mailing address:
  • Phone: 636-728-1777
  • Fax: 636-728-1793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2010003418
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: