Healthcare Provider Details

I. General information

NPI: 1467451369
Provider Name (Legal Business Name): DEBORAH LAVENDER P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLONNADE CTR
DES PERES MO
63131-4328
US

IV. Provider business mailing address

1133 COLONNADE CTR
DES PERES MO
63131-4328
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-6006
  • Fax: 314-821-6005
Mailing address:
  • Phone: 314-821-6006
  • Fax: 314-821-6005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberR0391
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: