Healthcare Provider Details

I. General information

NPI: 1639461700
Provider Name (Legal Business Name): MEGAN WALL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 06/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10916 SCHUETZ RD
SAINT LOUIS MO
63146-5704
US

IV. Provider business mailing address

10916 SCHUETZ RD
SAINT LOUIS MO
63146-5704
US

V. Phone/Fax

Practice location:
  • Phone: 314-692-8499
  • Fax:
Mailing address:
  • Phone: 314-692-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2011012299
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number11-02760
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: