Healthcare Provider Details

I. General information

NPI: 1962435107
Provider Name (Legal Business Name): ST. LOUIS PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 N OUTER 40 SUITE 205
CHESTERFIELD MO
63005-1364
US

IV. Provider business mailing address

17300 N OUTER 40 SUITE 205
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 Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number103326
License Number StateMO

VIII. Authorized Official

Name: MR. MICHAEL J GORMAN
Title or Position: OWNER
Credential: PT, MOMT
Phone: 636-728-1777