Provider Demographics
NPI:1205249257
Name:DANIELS, MARK (LAT, MS, ATC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DANIELS
Suffix:
Gender:M
Credentials:LAT, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S ELM AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4047
Mailing Address - Country:US
Mailing Address - Phone:417-839-9920
Mailing Address - Fax:
Practice Address - Street 1:630 S ELM AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-4047
Practice Address - Country:US
Practice Address - Phone:417-839-9920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-07
Last Update Date:2014-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00036OtherLICENSED ATHLETIC TRAINER