Provider Demographics
NPI:1679219638
Name:ST. JOHN, THEODORE JAMES (DPT)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JAMES
Last Name:ST. JOHN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5866 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8707
Mailing Address - Country:US
Mailing Address - Phone:989-573-8588
Mailing Address - Fax:989-573-8589
Practice Address - Street 1:5866 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-8707
Practice Address - Country:US
Practice Address - Phone:989-573-8588
Practice Address - Fax:989-573-8589
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501301844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS325792367996OtherDRIVERS LICENSE