Provider Demographics
NPI:1710409479
Name:NULL, CASEY (DPT)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:NULL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2913 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-4336
Mailing Address - Country:US
Mailing Address - Phone:417-425-5175
Mailing Address - Fax:
Practice Address - Street 1:2913 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-4336
Practice Address - Country:US
Practice Address - Phone:417-425-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010030685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist