Provider Demographics
NPI:1023142601
Name:PHAN, LYRA RIVERA (PT)
Entity type:Individual
Prefix:
First Name:LYRA
Middle Name:RIVERA
Last Name:PHAN
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 1:12858 STRATHEARN DR
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146
Mailing Address - Country:US
Mailing Address - Phone:314-307-1714
Mailing Address - Fax:
Practice Address - Street 1:250 NEW FLORISSANT RD S
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63013
Practice Address - Country:US
Practice Address - Phone:314-830-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist