Healthcare Provider Details

I. General information

NPI: 1609218742
Provider Name (Legal Business Name): CALLIE COPPEDGE EMMART PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 HWY 160 WEST
GAINESVILLE MO
65655
US

IV. Provider business mailing address

RR 3 BOX 147G
AVA MO
65608-8107
US

V. Phone/Fax

Practice location:
  • Phone: 417-679-4929
  • Fax:
Mailing address:
  • Phone: 417-683-0187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2009005438
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number2009005438
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: