Healthcare Provider Details

I. General information

NPI: 1073339420
Provider Name (Legal Business Name): KAREN GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 LEMAY FERRY RD
SAINT LOUIS MO
63125-4535
US

IV. Provider business mailing address

4521 SOUTHRIDGE MEADOWS DR
SAINT LOUIS MO
63128-2367
US

V. Phone/Fax

Practice location:
  • Phone: 314-939-1377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2015003450
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: