Provider Demographics
NPI:1699269928
Name:PHYSICAL THERAPY COLLECTIVE, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY COLLECTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LUCILLE
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:801-550-0373
Mailing Address - Street 1:3830 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4826
Mailing Address - Country:US
Mailing Address - Phone:801-550-0373
Mailing Address - Fax:
Practice Address - Street 1:4642 SHENANDOAH AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-3424
Practice Address - Country:US
Practice Address - Phone:314-664-6400
Practice Address - Fax:314-664-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001588222261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO161122142605024Medicaid