Provider Demographics
NPI:1669727103
Name:RICHARDSON, MARILYN J (PTA)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 40-30
Mailing Address - Street 2:
Mailing Address - City:WEAUBLEAU
Mailing Address - State:MO
Mailing Address - Zip Code:65774-9510
Mailing Address - Country:US
Mailing Address - Phone:417-298-5263
Mailing Address - Fax:
Practice Address - Street 1:600 EAST 7TH ST.
Practice Address - Street 2:
Practice Address - City:LOWRY CITY
Practice Address - State:MO
Practice Address - Zip Code:64763
Practice Address - Country:US
Practice Address - Phone:417-298-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010029437225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant