Provider Demographics
NPI:1801140710
Name:WEBER, MARILYN ANN (LPTA)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:ANN
Last Name:WEBER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 HOFFMANN LN
Mailing Address - Street 2:
Mailing Address - City:FULTS
Mailing Address - State:IL
Mailing Address - Zip Code:62244-1355
Mailing Address - Country:US
Mailing Address - Phone:618-458-7195
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117326225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant