Provider Demographics
NPI:1275767246
Name:GERHARDT, JUSTIN KEITH (PT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:KEITH
Last Name:GERHARDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 STARDUST DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6212
Mailing Address - Country:US
Mailing Address - Phone:573-221-8800
Mailing Address - Fax:573-221-1808
Practice Address - Street 1:3652 STARDUST DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6212
Practice Address - Country:US
Practice Address - Phone:573-221-8800
Practice Address - Fax:573-221-1808
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009006691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist