Provider Demographics
NPI:1083168033
Name:LANDRY, GINA (DPT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1939
Mailing Address - Country:US
Mailing Address - Phone:262-925-5000
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:3503 E. LAYTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1408
Practice Address - Country:US
Practice Address - Phone:414-489-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13075-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist