Basic Information
| Provider Information | |||||||||
| NPI: | 1740399476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROCHE | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | PT, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2454 W CLAY ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369164625 | ||||||||
| FaxNumber: | 6369164628 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 MEXICO RD | ||||||||
| Address2: | STE104 | ||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369399540 | ||||||||
| FaxNumber: | 6369399886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/24/2012 | ||||||||
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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 | 104831 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251H1200X | 1041100253 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | P00602661 | 01 | MO | RAILROAD MEDICARE | OTHER |