Healthcare Provider Details

I. General information

NPI: 1053247684
Provider Name (Legal Business Name): MIRELLA A GATTERDAM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20502 ROOSEVELT ST
ELKHORN NE
68022-4148
US

IV. Provider business mailing address

PO BOX 24607
OMAHA NE
68124-0607
US

V. Phone/Fax

Practice location:
  • Phone: 402-955-8000
  • Fax: 402-955-8001
Mailing address:
  • Phone: 402-955-5400
  • Fax: 402-955-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number4979
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: