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General NPI Number Information
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NPI Number | 1467597153
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Entity Type | Individual
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Provider Name | PAMELA MICHELLE MACON MPT
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Gender | Female
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 11365 DORSETT RD
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City | MARYLAND HEIGHTS
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State | MO
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Zip | 63043-3411
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Country | US
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Telephone | 314-872-6440
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Fax |
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Provider Business Mailing Address
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Address Line | 5 IRENE CT
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City | DES PERES
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State | MO
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Zip | 63131-4141
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Country | US
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Telephone | 314-568-7822
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 112634
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License Number State | MO
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