MEDICARE: PHYSICAL THERAPY COLLECTIVE, LLC

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	261QP2000X	Physical Therapy Clinic/Center	LC001588222	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699269928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL THERAPY COLLECTIVE, LLC

Provider Business Mailing Address
First Line	:	3830 HUMPHREY ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-4826
Country	:	US
Telephone Number	:	801-550-0373
Fax Number	:

Provider Business Practice Location Address
First Line	:	4642 SHENANDOAH AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-3424
Country	:	US
Telephone Number	:	314-664-6400
Fax Number	:	314-664-6401

Authorized Official
Title or Position	:	OWNER/ PHYSICAL THERAPIST
Name	:	MARY LUCILLE COOLEY
Credential	:	DPT
Telephone Number	:	801-550-0373

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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