Healthcare Provider Details

I. General information

NPI: 1194898288
Provider Name (Legal Business Name): LAURA D GWILLIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 05/09/2021
Certification Date: 05/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 C N OAK ST
VALDOSTA GA
31602-1781
US

IV. Provider business mailing address

1803 WILLIAMS ST
VALDOSTA GA
31602-2924
US

V. Phone/Fax

Practice location:
  • Phone: 229-245-0646
  • Fax: 229-245-8946
Mailing address:
  • Phone: 229-251-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: