Healthcare Provider Details

I. General information

NPI: 1487786638
Provider Name (Legal Business Name): ETHEL MAUREEN FRESE PT, DPT, CCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 CAROLINE ST ROOM 1005
SAINT LOUIS MO
63104-1111
US

IV. Provider business mailing address

3437 CAROLINE ST ROOM 1005
SAINT LOUIS MO
63104-1111
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8535
  • Fax: 314-977-8513
Mailing address:
  • Phone: 314-977-8535
  • Fax: 314-977-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00623
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: