Healthcare Provider Details

I. General information

NPI: 1770961153
Provider Name (Legal Business Name): MILDRED WOLTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 COEUR DE VILLE DR
CREVE COEUR MO
63141-6603
US

IV. Provider business mailing address

9001 PARKSHIRE CT
SAINT LOUIS MO
63126-2423
US

V. Phone/Fax

Practice location:
  • Phone: 314-453-7311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number2001009066
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: