Healthcare Provider Details

I. General information

NPI: 1366413551
Provider Name (Legal Business Name): LISA D GUMMERMAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 E ARMSTRONG AVE
PEORIA IL
61603-3201
US

IV. Provider business mailing address

27 PENDLETON WAY
BLOOMINGTON IL
61704-6243
US

V. Phone/Fax

Practice location:
  • Phone: 309-686-1177
  • Fax:
Mailing address:
  • Phone: 217-622-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: