Basic Information
| Provider Information | |||||||||
| NPI: | 1902901879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULSRUD-NEIBER | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1686 HENRY LUCKOW LN | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610081705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155474777 | ||||||||
| FaxNumber: | 8155471024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1686 HENRY LUCKOW LN | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610081705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155474777 | ||||||||
| FaxNumber: | 8155471024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-008204 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | K20025IL | 01 | IL | MEDICARE PTAN | OTHER |