Provider Demographics
NPI:1447564174
Name:SELF, LAURA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:SELF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 BOWLES AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2384
Mailing Address - Country:US
Mailing Address - Phone:636-334-3955
Mailing Address - Fax:
Practice Address - Street 1:1011 BOWLES AVE STE 150
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2384
Practice Address - Country:US
Practice Address - Phone:636-334-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist