Healthcare Provider Details

I. General information

NPI: 1427326925
Provider Name (Legal Business Name): TAWANA SPANN PT, MS, GCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4934 BERTHOLD AVE
SAINT LOUIS MO
63110-1408
US

IV. Provider business mailing address

4934 BERTHOLD AVE
SAINT LOUIS MO
63110-1408
US

V. Phone/Fax

Practice location:
  • Phone: 314-363-4078
  • Fax: 314-652-1881
Mailing address:
  • Phone: 314-363-4078
  • Fax: 314-652-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number112062
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number070012762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: