Provider Demographics
NPI:1265455398
Name:THREATT, PHILLIP L (ATC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:THREATT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:3301 BERRYWOOD DR
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6517
Practice Address - Country:US
Practice Address - Phone:573-449-8771
Practice Address - Fax:573-449-6563
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1035402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer