Provider Demographics
NPI:1073989042
Name:KLENKE, JUSTIN TYLER (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:KLENKE
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 1:14450 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5711
Mailing Address - Country:US
Mailing Address - Phone:314-434-6060
Mailing Address - Fax:314-434-6066
Practice Address - Street 1:14450 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5711
Practice Address - Country:US
Practice Address - Phone:314-434-6060
Practice Address - Fax:314-434-6066
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist