Healthcare Provider Details

I. General information

NPI: 1356034276
Provider Name (Legal Business Name): MARIS O'MALLEY EBELING DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 BELLEVUE AVE
RICHMOND HEIGHTS MO
63117-1827
US

IV. Provider business mailing address

6359 WATERMAN AVE
SAINT LOUIS MO
63130-4708
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-1978
  • Fax:
Mailing address:
  • Phone: 314-799-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: