Provider Demographics
NPI:1093497836
Name:GAMBREL, ETHAN BLAKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:BLAKE
Last Name:GAMBREL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1223
Mailing Address - Country:US
Mailing Address - Phone:618-534-6713
Mailing Address - Fax:606-302-5418
Practice Address - Street 1:1510 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1223
Practice Address - Country:US
Practice Address - Phone:618-534-6713
Practice Address - Fax:606-302-5418
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist