Provider Demographics
NPI:1063646537
Name:BERTKE, GWEN M (PTA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:BERTKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:02095 STATE ROUTE 219
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-9331
Mailing Address - Country:US
Mailing Address - Phone:419-394-6376
Mailing Address - Fax:
Practice Address - Street 1:02095 STATE ROUTE 219
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-9331
Practice Address - Country:US
Practice Address - Phone:419-394-6376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06511225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant