Basic Information
Provider Information | |||||||||
NPI: | 1447279153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNTER GAUB | ||||||||
FirstName: | MARY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUNTER | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3301 BERRYWOOD DR | ||||||||
Address2: | SUITE 204 | ||||||||
City: | COLUMBIA | ||||||||
State: | MO | ||||||||
PostalCode: | 652016517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5734498771 | ||||||||
FaxNumber: | 5734496563 | ||||||||
Practice Location | |||||||||
Address1: | 100 E DAVIS ST | ||||||||
Address2: |   | ||||||||
City: | FAYETTE | ||||||||
State: | MO | ||||||||
PostalCode: | 652481405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6602483053 | ||||||||
FaxNumber: | 6602482682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 01935 | MO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.