Provider Demographics
NPI:1689962490
Name:SURDAL, JULIE (DPT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:SURDAL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:STELLILNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:18691 OLD HIGHWAY 63 N
Mailing Address - Street 2:
Mailing Address - City:STURGEON
Mailing Address - State:MO
Mailing Address - Zip Code:65284-9145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:MO
Practice Address - Zip Code:65275-1165
Practice Address - Country:US
Practice Address - Phone:660-327-4125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO1999135163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist