Provider Demographics
NPI:1235859190
Name:GUSI, STEPHANIE AIRELLE CASTILLO
Entity Type:Individual
Prefix:
First Name:STEPHANIE AIRELLE
Middle Name:CASTILLO
Last Name:GUSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 SHERATON DR APT 325
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1335
Mailing Address - Country:US
Mailing Address - Phone:706-537-1822
Mailing Address - Fax:
Practice Address - Street 1:5300 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2199
Practice Address - Country:US
Practice Address - Phone:478-405-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty