Provider Demographics
NPI:1033629076
Name:GISH, CHANTEL BREEZE
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:BREEZE
Last Name:GISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ACTON ALY
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-3167
Mailing Address - Country:US
Mailing Address - Phone:717-875-1123
Mailing Address - Fax:
Practice Address - Street 1:1800 VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2376
Practice Address - Country:US
Practice Address - Phone:717-397-4831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE01677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant