Healthcare Provider Details

I. General information

NPI: 1679551568
Provider Name (Legal Business Name): GATEAU PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11855 HG TRUEMAN RD
LUSBY MD
20657-2855
US

IV. Provider business mailing address

11855 HG TRUEMAN RD
LUSBY MD
20657-2855
US

V. Phone/Fax

Practice location:
  • Phone: 410-326-3432
  • Fax: 410-326-2493
Mailing address:
  • Phone: 410-326-3432
  • Fax: 410-326-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BONNIE B GATEAU
Title or Position: CEO OWNER
Credential: PT
Phone: 410-326-3432