Provider Demographics
NPI:1811196140
Name:O'MALLEY, JOAN M (PT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9816 VERA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-3223
Mailing Address - Country:US
Mailing Address - Phone:314-843-0458
Mailing Address - Fax:
Practice Address - Street 1:9816 VERA CRUZ DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-3223
Practice Address - Country:US
Practice Address - Phone:314-843-0458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist