Provider Demographics
NPI:1649888694
Name:JOHN, FOLASHADE (DPT)
Entity type:Individual
Prefix:
First Name:FOLASHADE
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 FOREST PKWY APT H
Mailing Address - Street 2:
Mailing Address - City:VALLEY PARK
Mailing Address - State:MO
Mailing Address - Zip Code:63088-1050
Mailing Address - Country:US
Mailing Address - Phone:314-651-6156
Mailing Address - Fax:
Practice Address - Street 1:11160 VILLAGE NORTH DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6159
Practice Address - Country:US
Practice Address - Phone:314-355-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist