Healthcare Provider Details

I. General information

NPI: 1659619690
Provider Name (Legal Business Name): ELAYNE KAY GEBA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2013
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 FOUNDRY ST UNIT B
WATERBURY VT
05676-1503
US

IV. Provider business mailing address

30 FOUNDRY ST UNIT B
WATERBURY VT
05676-1503
US

V. Phone/Fax

Practice location:
  • Phone: 802-560-8757
  • Fax: 484-848-5190
Mailing address:
  • Phone: 802-560-8757
  • Fax: 484-848-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017667
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01350400
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040.0134720
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: