Provider Demographics
NPI:1164713475
Name:STADEN, CONNIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:STADEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WHITE PLAINS DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2039
Mailing Address - Country:US
Mailing Address - Phone:314-580-8900
Mailing Address - Fax:
Practice Address - Street 1:14795 GREENLOCH CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5518
Practice Address - Country:US
Practice Address - Phone:314-580-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2081338225200000X
MO2010027326225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant