Provider Demographics
NPI:1033784772
Name:CHASTAIN, CONNOR (DPT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:CHASTAIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 WESTGATE CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8396
Mailing Address - Country:US
Mailing Address - Phone:615-678-0024
Mailing Address - Fax:615-465-0144
Practice Address - Street 1:113 W LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2915
Practice Address - Country:US
Practice Address - Phone:314-962-6015
Practice Address - Fax:314-628-6001
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016020804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016020804OtherPHYSICAL THERAPY LICENSE