Healthcare Provider Details

I. General information

NPI: 1629849195
Provider Name (Legal Business Name): CARLY O'DONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S KIRKWOOD RD
SAINT LOUIS MO
63122-7254
US

IV. Provider business mailing address

411 WOODBINE CT
ARNOLD MO
63010-3635
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-7554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024001360
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: