Healthcare Provider Details

I. General information

NPI: 1952665713
Provider Name (Legal Business Name): EMILY RENEE GROZDANIC ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2454 W CLAY ST
SAINT CHARLES MO
63301-2548
US

IV. Provider business mailing address

5353A DEVONSHIRE AVE
SAINT LOUIS MO
63109-2305
US

V. Phone/Fax

Practice location:
  • Phone: 636-949-3926
  • Fax:
Mailing address:
  • Phone: 314-488-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2010023045
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: