Basic Information
| Provider Information | |||||||||
| NPI: | 1750930897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AUSTIN | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | ALEXANDRIA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 352 MASON RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633047284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362886100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15425 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630113077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362206969 | ||||||||
| FaxNumber: | 6362206973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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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 | 225200000X | 2019034111 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.