Provider Demographics
NPI:1376777680
Name:MCINNES, GWEN (PT)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:MCINNES
Suffix:
Gender:F
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:ONE CIVIC PLAZA
Mailing Address - Street 2:SUITE 625
Mailing Address - City:CARSON,
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:866-414-0448
Mailing Address - Fax:310-549-4700
Practice Address - Street 1:ONE CIVIC PLAZA
Practice Address - Street 2:SUITE 625
Practice Address - City:CARSON,
Practice Address - State:CA
Practice Address - Zip Code:90745
Practice Address - Country:US
Practice Address - Phone:866-414-0448
Practice Address - Fax:310-549-4700
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35743225100000X
MEPT3134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist