=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194511758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLC THERAPY PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5263 GOLDEN GATE PKWY STE E
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-7601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-352-9884
-----------------------------------------------------
Fax | 239-228-3291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5263 GOLDEN GATE PKWY STE E
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-7601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-352-9884
-----------------------------------------------------
Fax | 239-228-3291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY/PHYSICAL THERAPIST
-----------------------------------------------------
Name | MARYROSE GULAPA
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 239-352-9884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------