Basic Information
| Provider Information | |||||||||
| NPI: | 1033784772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHASTAIN | ||||||||
| FirstName: | CONNOR | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 WESTGATE CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370278396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156780024 | ||||||||
| FaxNumber: | 6154650144 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 W LOCKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | WEBSTER GROVES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631192915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149626015 | ||||||||
| FaxNumber: | 3146286001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2016020804 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2016020804 | 01 | MO | PHYSICAL THERAPY LICENSE | OTHER |