Healthcare Provider Details

I. General information

NPI: 1912416173
Provider Name (Legal Business Name): CORY WHEELER GEBHARD PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 CLOQUET AVE
CLOQUET MN
55720-1622
US

IV. Provider business mailing address

1204 CLOQUET AVE
CLOQUET MN
55720-1622
US

V. Phone/Fax

Practice location:
  • Phone: 218-878-0805
  • Fax: 218-878-0794
Mailing address:
  • Phone: 218-878-0805
  • Fax: 218-878-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10828
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: