Provider Demographics
NPI:1225391071
Name:GAVIN, MARIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:GAVIN
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 1:573 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4018
Mailing Address - Country:US
Mailing Address - Phone:815-754-9417
Mailing Address - Fax:
Practice Address - Street 1:573 BUSH ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4018
Practice Address - Country:US
Practice Address - Phone:815-754-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.008994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist