Provider Demographics
NPI:1477658631
Name:ALLEN, MAURY (PT)
Entity Type:Individual
Prefix:
First Name:MAURY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CLUB VILLAGE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4409
Mailing Address - Country:US
Mailing Address - Phone:573-256-2777
Mailing Address - Fax:573-256-2764
Practice Address - Street 1:1100 CLUB VILLAGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4409
Practice Address - Country:US
Practice Address - Phone:573-256-2777
Practice Address - Fax:573-256-2764
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO485883813Medicaid
MO000013939Medicare ID - Type Unspecified