Provider Demographics
NPI:1275910564
Name:GILLUM, GREGORY SCOTT (DPT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:GILLUM
Suffix:
Gender:M
Credentials:DPT
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 491
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98941-0491
Mailing Address - Country:US
Mailing Address - Phone:509-260-1051
Mailing Address - Fax:888-538-7694
Practice Address - Street 1:722 E UNIVERSITY WAY
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-2947
Practice Address - Country:US
Practice Address - Phone:509-962-1553
Practice Address - Fax:888-538-7694
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60535435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist