Provider Demographics
NPI:1467485128
Name:HUSBY, GORDON D (PT)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:D
Last Name:HUSBY
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 1:1720 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-8206
Mailing Address - Country:US
Mailing Address - Phone:815-344-5643
Mailing Address - Fax:
Practice Address - Street 1:420 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3711
Practice Address - Country:US
Practice Address - Phone:815-356-5200
Practice Address - Fax:815-356-5262
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2013-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-004524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213256Medicare ID - Type UnspecifiedPT PROVIDER NUMBER