Active NPI
Macy Sophanavong, DPT
- Physical Therapist
- Saint Peters, MO
National Provider Identifier
1174357453
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 2024034830
- Practice address
- 3639 N Saint Peters Pkwy
Saint Peters, MO 63376-7303 - Phone
- (309) 256-2899
- NPI assigned
- Aug 28, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 2024034830 | MO | Primary |
Addresses
Primary practice location
3639 N Saint Peters Pkwy
Saint Peters, MO 63376-7303
Mailing address
6658 Berthold Ave Apt 1F
Saint Louis, MO 63139-3319
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2024034830 | MO | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1724803200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1724803200000",
"number": "1174357453",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6658 BERTHOLD AVE APT 1F",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631393319"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3639 N SAINT PETERS PKWY",
"city": "SAINT PETERS",
"state": "MO",
"postal_code": "633767303",
"telephone_number": "309-256-2899"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SOPHANAVONG",
"first_name": "MACY",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-08-28",
"last_updated": "2024-08-28",
"certification_date": "2024-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "MO",
"license": "2024034830",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Peters, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.