Provider Demographics
NPI:1356073175
Name:VYTLACIL, MELLI ANJA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MELLI
Middle Name:ANJA
Last Name:VYTLACIL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 VICTOR ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-4326
Mailing Address - Country:US
Mailing Address - Phone:323-317-1164
Mailing Address - Fax:
Practice Address - Street 1:1001 S KIRKWOOD RD STE 150
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-7251
Practice Address - Country:US
Practice Address - Phone:314-821-7554
Practice Address - Fax:314-821-0048
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022024262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty