Basic Information
| Provider Information | |||||||||
| NPI: | 1417963240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLES | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | GORMASTIC | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GORMASTIC | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024895730 | ||||||||
| FaxNumber: | 5024895733 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 FERN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402133529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029644889 | ||||||||
| FaxNumber: | 5029649769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 004448 | KY | N | Other Service Providers | Specialist | 225100000X | 05008800A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 004448 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000064465 | 01 | KY | ANTHEM/BCBS | OTHER |