Provider Demographics
NPI:1710198049
Name:MCGLYNN, MYCHELLE LUANN (PTA)
Entity type:Individual
Prefix:
First Name:MYCHELLE
Middle Name:LUANN
Last Name:MCGLYNN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 RACCOON LN
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-9154
Mailing Address - Country:US
Mailing Address - Phone:417-759-1774
Mailing Address - Fax:
Practice Address - Street 1:331 HOSPITAL DR STE D
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9251
Practice Address - Country:US
Practice Address - Phone:417-533-6315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024405225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant