Basic Information
| Provider Information | |||||||||
| NPI: | 1245284207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELISLE | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANHOUGHTON | ||||||||
| OtherFirstName: | WENDI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 241686 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361241686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343962115 | ||||||||
| FaxNumber: | 3343962115 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346887155 | ||||||||
| FaxNumber: | 3346167615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH4666 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.