Basic Information
| Provider Information | |||||||||
| NPI: | 1427375914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYNARD | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GLAZNER | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17134 BEL RAY PL | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640125331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162264011 | ||||||||
| FaxNumber: | 8165246115 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163803344 | ||||||||
| FaxNumber: | 8163803044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 01/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2010033320 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | MA4370050 | 01 | MO | MEDICARE PTAN | OTHER | 44388053 | 01 | BCBS KC | OTHER |