MEDICARE: BRITTANY JESSICA COUNTERMAN MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2005019708	MO

General Provider Information

NPI Number	:	1356655914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRITTANY JESSICA COUNTERMAN MPT

Provider Business Mailing Address
First Line	:	1905 BRIARFIELD DR
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-6493
Country	:	US
Telephone Number	:	314-420-6779
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 HARBOR BEND CT
Second Line	:
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-1478
Country	:	US
Telephone Number	:	636-695-2070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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