Healthcare Provider Details

I. General information

NPI: 1861217812
Provider Name (Legal Business Name): ERIKA GRIDER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3789 NEW TOWN BLVD
SAINT CHARLES MO
63301-4358
US

IV. Provider business mailing address

3789 NEW TOWN BLVD
SAINT CHARLES MO
63301-4358
US

V. Phone/Fax

Practice location:
  • Phone: 636-669-2377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2021043986
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: