Provider Demographics
NPI:1104021823
Name:MILLER, MARY REBECCA (MSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:REBECCA
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:REBECCA
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:13537 BARRETT PARKWAY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5899
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:3950 VOGEL RD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-3790
Practice Address - Country:US
Practice Address - Phone:314-842-2990
Practice Address - Fax:314-842-5162
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007000363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist