Provider Demographics
NPI:1003988932
Name:GAMMEL, JOHANNS MAURICIO (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHANNS
Middle Name:MAURICIO
Last Name:GAMMEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ANDOVER TER
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3719
Mailing Address - Country:US
Mailing Address - Phone:551-579-3588
Mailing Address - Fax:
Practice Address - Street 1:251 ROCK RD
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-1745
Practice Address - Country:US
Practice Address - Phone:201-445-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00260000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686503Medicare ID - Type Unspecified