Provider Demographics
NPI:1518430453
Name:PELLIKAN, JOSHUA BRADLEY
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BRADLEY
Last Name:PELLIKAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 FRANCIS PL STE 115
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-644-1978
Mailing Address - Fax:314-644-5730
Practice Address - Street 1:950 FRANCIS PL STE 115
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-644-1978
Practice Address - Fax:314-644-5730
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018045086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist