Basic Information
| Provider Information | |||||||||
| NPI: | 1639475403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVRILOS | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONSTANTINE | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 106 W FAIRMONT AVE | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161052852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307747463 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 121 ENCLAVE DR | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161053207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242027908 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT022351 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT013503 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1639475403 | 01 | NPI | OTHER |