Provider Demographics
NPI:1578168142
Name:FLYNN, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:FLYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:HAARMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:1623 ANSONBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5647
Mailing Address - Country:US
Mailing Address - Phone:314-406-6384
Mailing Address - Fax:
Practice Address - Street 1:2600 COMPASS RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8001
Practice Address - Country:US
Practice Address - Phone:877-787-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty