Provider Demographics
NPI:1164023982
Name:GANSKE, TABITHA LYN (PTA)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYN
Last Name:GANSKE
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 1:106 ECHO VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1498
Mailing Address - Country:US
Mailing Address - Phone:618-401-3307
Mailing Address - Fax:
Practice Address - Street 1:27 AUERBACH PL
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1596
Practice Address - Country:US
Practice Address - Phone:618-288-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019027272208100000X
IL160.008904208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation