Healthcare Provider Details

I. General information

NPI: 1366772881
Provider Name (Legal Business Name): KAREN MARIE RANDOLPH MPT, COMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9437 OLIVE BLVD
OLIVETTE MO
63132-3130
US

IV. Provider business mailing address

455 FALL RIVER LN
SAINT CHARLES MO
63304-8501
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-9500
  • Fax:
Mailing address:
  • Phone: 314-791-5884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2009038744
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: