Provider Demographics
NPI:1194292565
Name:WEBB, MICHAEL JOE (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOE
Last Name:WEBB
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 ELLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1522
Mailing Address - Country:US
Mailing Address - Phone:314-229-9637
Mailing Address - Fax:
Practice Address - Street 1:15480 CLAYTON RD STE 103
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3172
Practice Address - Country:US
Practice Address - Phone:314-229-9637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009007186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty