Provider Demographics
NPI:1467965939
Name:GAIN, CARLA (PT)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:GAIN
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 1:105 W A ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1326
Mailing Address - Country:US
Mailing Address - Phone:618-234-4294
Mailing Address - Fax:
Practice Address - Street 1:118 WESTHAVEN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3264
Practice Address - Country:US
Practice Address - Phone:618-257-9201
Practice Address - Fax:618-257-9201
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-0056472251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics