Provider Demographics
NPI:1497438212
Name:PRINCE, MAYA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:MARIE
Last Name:PRINCE
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 1:2315 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8659
Mailing Address - Country:US
Mailing Address - Phone:636-385-5277
Mailing Address - Fax:636-385-5277
Practice Address - Street 1:140 LONG RD STE 201
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1282
Practice Address - Country:US
Practice Address - Phone:636-265-1505
Practice Address - Fax:636-266-2112
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023004476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist