Basic Information
| Provider Information | |||||||||
| NPI: | 1831854066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | GABRIELLA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 12TH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619203535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172596799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 716 18TH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619202382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173457054 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2021 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 160.009354 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.