Provider Demographics
NPI:1467813550
Name:CORDRAY, GWENDOLYN (PT)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:CORDRAY
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 1:2027 WHISTLING SWAN CIR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8234
Mailing Address - Country:US
Mailing Address - Phone:860-967-8083
Mailing Address - Fax:
Practice Address - Street 1:200 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1393
Practice Address - Country:US
Practice Address - Phone:920-338-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024442225100000X
WI14083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist