Provider Demographics
NPI:1104018233
Name:GULLIKSEN, PAUL K (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:K
Last Name:GULLIKSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 W GRANADA BLVD
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8259
Mailing Address - Country:US
Mailing Address - Phone:386-265-1925
Mailing Address - Fax:386-265-1926
Practice Address - Street 1:1275 W GRANADA BLVD
Practice Address - Street 2:SUITE 6B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8259
Practice Address - Country:US
Practice Address - Phone:386-265-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00076722251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY3762ZMedicare PIN