Healthcare Provider Details

I. General information

NPI: 1528669827
Provider Name (Legal Business Name): DENNIS KIRK SISSOM LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BREEZE PARK DR
WELDON SPRING MO
63304-9139
US

IV. Provider business mailing address

26 BROZ RD
BELLFLOWER MO
63333-2700
US

V. Phone/Fax

Practice location:
  • Phone: 636-229-5996
  • Fax: 636-720-3388
Mailing address:
  • Phone: 314-420-8954
  • Fax: 636-720-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117159
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: