Provider Demographics
NPI:1972907970
Name:HUTTON, MEREDITH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:HUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:CLARKSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:236 SANDRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 FRANK SCOTT PKWY E
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7342
Practice Address - Country:US
Practice Address - Phone:618-624-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014026915225100000X
IL070.021135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist