=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609419480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR GORRELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2019
-----------------------------------------------------
Last Update Date | 10/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 6TH ST STE 101
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-8510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14240 BULL RAPIDS RD
-----------------------------------------------------
City | GRABILL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46741-9623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-466-0127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05013527A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 11435288-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT61002252
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------