Healthcare Provider Details

I. General information

NPI: 1932032778
Provider Name (Legal Business Name): ANDRE D WHITLEY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N NEW BALLAS RD STE 225
SAINT LOUIS MO
63141-6886
US

IV. Provider business mailing address

7394 DEMETER DR
ATLANTA GA
30349-7648
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-8700
  • Fax:
Mailing address:
  • Phone: 314-276-6129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2026022382
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: