Healthcare Provider Details

I. General information

NPI: 1407803737
Provider Name (Legal Business Name): CAROLYN JEAN GUM M.S.,P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8724 SARGENT CREEK LN
INDIANAPOLIS IN
46256-1376
US

IV. Provider business mailing address

8724 SARGENT CREEK LN
INDIANAPOLIS IN
46256-1376
US

V. Phone/Fax

Practice location:
  • Phone: 317-913-0350
  • Fax: 317-913-0351
Mailing address:
  • Phone: 317-577-0763
  • Fax: 317-913-0351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05001785A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: