Provider Demographics
NPI:1598075400
Name:POORE, JANICE (PTA)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:POORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 LINDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7730 FORSYTH BLVD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1810
Practice Address - Country:US
Practice Address - Phone:800-677-1238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117974225200000X
IL160.003068225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant