Individual
SUSY ALIAS
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1 JEFFERSON BARRACKS DR, JEFFERSON BARRACKS, VA, SAINT LOUIS, MO 63125-4181
(314) 894-6629
(314) 845-5077
Mailing address
1 JB DRIVE, JEFFERSON BARRACKS, ST, LOUIS, MO 63125
(314) 894-6629
(314) 845-5077
Taxonomy
Speciality
Code
Description
License number
State
204D00000X
Neuromusculoskeletal Medicine & OMM Physician
R9895
MO
208100000X
Physical Medicine & Rehabilitation Physician
Primary
R9895
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NONE
PHYSICIAN
MO
Enumeration date
05/15/2006
Last updated
09/11/2025
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