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General NPI Number Information
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NPI Number | 1508331299
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Entity Type | Individual
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Provider Name | TERRENCE MICHAEL GAUTHIER
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Gender | Male
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Dates
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Enumeration Date | 10/09/2018
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Last Update Date | 10/09/2018
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Provider Practice Location Address
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Address Line | 3100 SHORE DR
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City | VIRGINIA BEACH
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State | VA
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Zip | 23451-1199
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Country | US
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Telephone | 758-496-1689
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Fax |
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Provider Business Mailing Address
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Address Line | 3904 SEEMAN RD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-2464
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Country | US
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Telephone | 619-204-0655
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306602987
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License Number State | VA
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