Healthcare Provider Details

I. General information

NPI: 1023356474
Provider Name (Legal Business Name): MHT SENIOR WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9191 W FLORISSANT AVE STE 200
SAINT LOUIS MO
63136-1424
US

IV. Provider business mailing address

9191 W FLORISSANT AVE STE 200
SAINT LOUIS MO
63136-1424
US

V. Phone/Fax

Practice location:
  • Phone: 314-524-3958
  • Fax: 314-524-3959
Mailing address:
  • Phone: 314-524-3958
  • Fax: 314-524-3959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number116922
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2008020852
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117525
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2007006528
License Number StateMO

VIII. Authorized Official

Name: DIONNESHAE FORLAND
Title or Position: OWNER
Credential:
Phone: 314-524-3958