Provider Demographics
NPI:1952375594
Name:ST MARIE, MONIQUE L (PT)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:L
Last Name:ST MARIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 OSHARA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1417
Mailing Address - Country:US
Mailing Address - Phone:719-659-6651
Mailing Address - Fax:
Practice Address - Street 1:49 OSHARA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-1417
Practice Address - Country:US
Practice Address - Phone:719-659-6651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25520225100000X
NM20240116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804246Medicare ID - Type Unspecified