Provider Demographics
NPI:1023607405
Name:BOCK, COLLEEN (PTA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7421 MEXICO RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1369
Mailing Address - Country:US
Mailing Address - Phone:636-757-6543
Mailing Address - Fax:636-695-4337
Practice Address - Street 1:7421 MEXICO RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1369
Practice Address - Country:US
Practice Address - Phone:636-757-6543
Practice Address - Fax:636-695-4337
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115995225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant