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NPI Code Detail

MEDICARE: ELLEN GAVIN PT, DPT

MEDICARE: ELLEN GAVIN PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist26507MD
2225100000XPhysical TherapistPT004264WV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
126507OTHERMDMARYLAND BOARD OF PHYSICAL THERAPY

General Provider Information

NPI Number : 1457881161
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLEN GAVIN PT, DPT
Provider Business Mailing Address
First Line : 208 OLD MILL RD
Second Line :
City : MARTINSBURG
State : WV
Zip : 25401-9219
Country : US
Telephone Number : 304-263-5680
Fax Number :
Provider Business Practice Location Address
First Line : 208 OLD MILL RD
Second Line :
City : MARTINSBURG
State : WV
Zip : 25401-9219
Country : US
Telephone Number : 304-263-5680
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2017
Last Update Date : 04/07/2022

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