Provider Demographics
NPI:1447642640
Name:ULRICH, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:ULRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CHASTITY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-7355
Mailing Address - Country:US
Mailing Address - Phone:636-448-0464
Mailing Address - Fax:
Practice Address - Street 1:6700 ANTIOCH RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-1497
Practice Address - Country:US
Practice Address - Phone:888-652-9225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014041498225200000X
KSKS14-02633225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant