Provider Demographics
NPI:1336500859
Name:BANTIS, GILLIAN VIRGINIA (PT, DPT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:GILLIAN
Middle Name:VIRGINIA
Last Name:BANTIS
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:MS
Other - First Name:GILLIAN
Other - Middle Name:VIRGINIA
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OCS
Mailing Address - Street 1:3230 E. IMPERIAL HWY.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6735
Mailing Address - Country:US
Mailing Address - Phone:714-988-8110
Mailing Address - Fax:714-988-8111
Practice Address - Street 1:250 E. YALE LOOP
Practice Address - Street 2:STE. 201
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604
Practice Address - Country:US
Practice Address - Phone:949-265-2442
Practice Address - Fax:949-265-2448
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291221225100000X
CA291221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist