Provider Demographics
NPI:1407803737
Name:GUM, CAROLYN JEAN (MS,PT)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:JEAN
Last Name:GUM
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8724 SARGENT CREEK LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1376
Mailing Address - Country:US
Mailing Address - Phone:317-577-0763
Mailing Address - Fax:317-913-0351
Practice Address - Street 1:8724 SARGENT CREEK LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1376
Practice Address - Country:US
Practice Address - Phone:317-913-0350
Practice Address - Fax:317-913-0351
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001785A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN352101298100OtherCARESOURCE
IN179390Medicare ID - Type Unspecified