Provider Demographics
NPI:1194854414
Name:GORMAN-BADAR, DEBRA A (PT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:GORMAN-BADAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2240
Mailing Address - Country:US
Mailing Address - Phone:406-563-2420
Mailing Address - Fax:406-563-2420
Practice Address - Street 1:117 E 3RD ST
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2240
Practice Address - Country:US
Practice Address - Phone:406-563-2420
Practice Address - Fax:406-563-2420
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT348595Medicaid
MT61765OtherBLUECROSSBLUESHIELD OF MT