Healthcare Provider Details

I. General information

NPI: 1912891193
Provider Name (Legal Business Name): BRENDAN GROSS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9326 OLIVE BLVD STE 100
OLIVETTE MO
63132-3257
US

IV. Provider business mailing address

14515 N OUTER 40 RD STE 110
CHESTERFIELD MO
63017-5746
US

V. Phone/Fax

Practice location:
  • Phone: 314-784-9646
  • Fax:
Mailing address:
  • Phone: 314-434-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2025017764
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: