Provider Demographics
NPI:1356840607
Name:DURHAM, ANGELA (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14515 NORTH OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5791
Mailing Address - Country:US
Mailing Address - Phone:314-434-8680
Mailing Address - Fax:
Practice Address - Street 1:1391 SMIZER MILL RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7306
Practice Address - Country:US
Practice Address - Phone:636-305-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist