Provider Demographics
NPI:1588014872
Name:RUBIN, MARILYN CARROL (PT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:CARROL
Last Name:RUBIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 HIDDEN RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1171
Mailing Address - Country:US
Mailing Address - Phone:314-680-6040
Mailing Address - Fax:
Practice Address - Street 1:11960 WESTLINE INDUSTRIAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3209
Practice Address - Country:US
Practice Address - Phone:314-819-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01022225100000X
IL070.016091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist