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General NPI Number Information
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NPI Number | 1780453308
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Entity Type | Individual
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Provider Name | KONNER SLOANE STREET DPT
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Gender | Female
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Dates
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Enumeration Date | 12/22/2023
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 6800 STATE ROUTE 162
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City | MARYVILLE
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State | IL
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Zip | 62062
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Country | US
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Telephone | 618-288-5711
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Fax |
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Provider Business Mailing Address
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Address Line | 6800 STATE ROUTE 162
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City | MARYVILLE
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State | IL
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Zip | 62062-8500
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Country | US
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Telephone | 618-288-5711
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 008995
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 008995
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.029219
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License Number State | IL
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