Healthcare Provider Details

I. General information

NPI: 1710303078
Provider Name (Legal Business Name): CASEY RAY GILLICK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 ROUTE 206, SUITE 3 NOVACARE REHABILITATION
SOUTHAMPTON NJ
08088
US

IV. Provider business mailing address

1805 ROUTE 206, SUITE 3
SOUTHAMPTON NJ
08088
US

V. Phone/Fax

Practice location:
  • Phone: 609-859-2426
  • Fax: 609-859-2537
Mailing address:
  • Phone: 609-859-2426
  • Fax: 609-859-2537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01536800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT023282
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: