Healthcare Provider Details

I. General information

NPI: 1356073175
Provider Name (Legal Business Name): MELLI ANJA VYTLACIL PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD STE 150
KIRKWOOD MO
63122-7251
US

IV. Provider business mailing address

1216 VICTOR ST
SAINT LOUIS MO
63104-4326
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7554
  • Fax: 314-821-0048
Mailing address:
  • Phone: 323-317-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2022024262
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: