Provider Demographics
NPI:1861743817
Name:PERNELL, MARY SUSAN (LPTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:PERNELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA
Mailing Address - Street 1:411 ROBERT AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-3526
Mailing Address - Country:US
Mailing Address - Phone:314-524-6191
Mailing Address - Fax:314-524-6191
Practice Address - Street 1:2011 CORONA RD STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2548
Practice Address - Country:US
Practice Address - Phone:314-543-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-29
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116138225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant