Provider Demographics
NPI:1760964605
Name:CHACKO, NEVIYA ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:NEVIYA
Middle Name:ROSE
Last Name:CHACKO
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 1:29 RONNIES PLZ
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-3552
Mailing Address - Country:US
Mailing Address - Phone:314-843-5667
Mailing Address - Fax:
Practice Address - Street 1:29 RONNIES PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3552
Practice Address - Country:US
Practice Address - Phone:312-843-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028390225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty