Provider Demographics
NPI:1225708761
Name:GILLIS, VIVIAN FAITH (PTA)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:FAITH
Last Name:GILLIS
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:PO BOX 2661
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30514-2661
Mailing Address - Country:US
Mailing Address - Phone:602-463-0135
Mailing Address - Fax:
Practice Address - Street 1:60 NO NAME AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:FL
Practice Address - Zip Code:33635
Practice Address - Country:US
Practice Address - Phone:813-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCTA7686225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant