Provider Demographics
NPI:1114327160
Name:GULLEDGE, AMY (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GULLEDGE
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60481
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-0481
Mailing Address - Country:US
Mailing Address - Phone:480-524-0321
Mailing Address - Fax:480-420-4139
Practice Address - Street 1:2121 S MILL AVE STE 209
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2136
Practice Address - Country:US
Practice Address - Phone:480-524-0321
Practice Address - Fax:480-420-4139
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ110842251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic