Provider Demographics
NPI:1891118410
Name:THRELKELD, DIANE (DPT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:THRELKELD
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 1:647 SPIRIT AIRPARK WEST DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1032
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:
Practice Address - Street 1:138 JUNCTION DR
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-4322
Practice Address - Country:US
Practice Address - Phone:618-636-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist