Provider Demographics
NPI:1174357453
Name:SOPHANAVONG, MACY (DPT)
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:SOPHANAVONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6658 BERTHOLD AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3639 N SAINT PETERS PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7303
Practice Address - Country:US
Practice Address - Phone:309-256-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024034830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist