Provider Demographics
NPI:1619117942
Name:OLIPHANT, AMBER ELISE (MPT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ELISE
Last Name:OLIPHANT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:ELISE
Other - Last Name:DANNENMUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2454 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2548
Mailing Address - Country:US
Mailing Address - Phone:636-916-4625
Mailing Address - Fax:636-916-4628
Practice Address - Street 1:4800 MEXICO RD
Practice Address - Street 2:STE 104
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-939-9540
Practice Address - Fax:636-939-9886
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07525R225100000X
MO2004035080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12206763OtherCAQH ID
MO991643012Medicare PIN