Basic Information
Provider Information | |||||||||
NPI: | 1669459111 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAILLARD | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | BETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 S RIVER RD | ||||||||
Address2: | UNIT 58 | ||||||||
City: | BEDFORD | ||||||||
State: | NH | ||||||||
PostalCode: | 031106751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033836454 | ||||||||
FaxNumber: | 7038105494 | ||||||||
Practice Location | |||||||||
Address1: | 5 CLINTON ST | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NH | ||||||||
PostalCode: | 033012303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6032243511 | ||||||||
FaxNumber: | 6032243556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 08/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT 28033 | CA | N |   | Other Service Providers | Specialist |   | 225100000X | 3763 | NH | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.