Provider Demographics
NPI:1962103945
Name:BACH, ANNETTE MARIE
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:BACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16585 CARRIAGE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1402
Mailing Address - Country:US
Mailing Address - Phone:314-803-3118
Mailing Address - Fax:
Practice Address - Street 1:16585 CARRIAGE VIEW CT
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1402
Practice Address - Country:US
Practice Address - Phone:314-803-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116988225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant