Healthcare Provider Details

I. General information

NPI: 1023214517
Provider Name (Legal Business Name): IVANA HANZELKOVA LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 FORSYTH BLVD
SAINT LOUIS MO
63105-1817
US

IV. Provider business mailing address

10720 LISA MARIE CT
SAINT LOUIS MO
63123-6122
US

V. Phone/Fax

Practice location:
  • Phone: 800-677-1202
  • Fax:
Mailing address:
  • Phone: 314-849-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: