Basic Information
| Provider Information | |||||||||
| NPI: | 1841470515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUPTILL | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1242 11 STREET | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 994032490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097582523 | ||||||||
| FaxNumber: | 5092952952 | ||||||||
| Practice Location | |||||||||
| Address1: | 1242 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 994032815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097582523 | ||||||||
| FaxNumber: | 5092952952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00008222 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT1541 | ID | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.