Healthcare Provider Details

I. General information

NPI: 1033463864
Provider Name (Legal Business Name): JULIE SODDY-GAMBLIN CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

2112 S MONTCLAIR AVE
BLOOMINGTON IN
47401-6814
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-8230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMT21204250
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: