Provider Demographics
NPI:1427326925
Name:SPANN, TAWANA (PT, MS, GCS)
Entity type:Individual
Prefix:MS
First Name:TAWANA
Middle Name:
Last Name:SPANN
Suffix:
Gender:F
Credentials:PT, MS, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4934 BERTHOLD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1408
Mailing Address - Country:US
Mailing Address - Phone:314-363-4078
Mailing Address - Fax:314-652-1881
Practice Address - Street 1:4934 BERTHOLD AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1408
Practice Address - Country:US
Practice Address - Phone:314-363-4078
Practice Address - Fax:314-652-1881
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1120622251G0304X
IL0700127622251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics