Provider Demographics
NPI:1255772091
Name:WURM, LACI J (DPT, ATC)
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:J
Last Name:WURM
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:LACI
Other - Middle Name:J
Other - Last Name:DURLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13537 BARRETT PARKWAY DR
Mailing Address - Street 2:STE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5899
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:3101 RECREATION DR
Practice Address - Street 2:STE 130
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-6107
Practice Address - Country:US
Practice Address - Phone:636-239-9979
Practice Address - Fax:636-239-5442
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist