Healthcare Provider Details

I. General information

NPI: 1558017632
Provider Name (Legal Business Name): TORI E THERRIEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2022
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 7011B
SAINT LOUIS MO
63141-8275
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 7011B
SAINT LOUIS MO
63141-8275
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6840
  • Fax:
Mailing address:
  • Phone: 314-251-6840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025035866
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA3175
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3175
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3175
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: