Healthcare Provider Details

I. General information

NPI: 1013686567
Provider Name (Legal Business Name): ERIN MCCULLOUGH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 FINKMAN ST # 1F
SAINT LOUIS MO
63109-3540
US

IV. Provider business mailing address

5409 FINKMAN ST # 1F
SAINT LOUIS MO
63109-3540
US

V. Phone/Fax

Practice location:
  • Phone: 314-304-5394
  • Fax:
Mailing address:
  • Phone: 314-304-5394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2019027372
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: