Provider Demographics
NPI:1457460107
Name:ROSHELL, MARK W (MS PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:ROSHELL
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:
Other - Last Name:ROSHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MIDDLE NAME
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:784 GRAVOIS BLUFFS BLVD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7726
Practice Address - Country:US
Practice Address - Phone:636-349-8060
Practice Address - Fax:636-349-9171
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist