Provider Demographics
NPI:1477527596
Name:GILLETTE, CORDIAL M (PHD, AT, LAT)
Entity Type:Individual
Prefix:MRS
First Name:CORDIAL
Middle Name:M
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:PHD, AT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3742
Mailing Address - Country:US
Mailing Address - Phone:608-785-8196
Mailing Address - Fax:
Practice Address - Street 1:1725 STATE ST.
Practice Address - Street 2:214 MITCHELL HALL
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3742
Practice Address - Country:US
Practice Address - Phone:608-785-8196
Practice Address - Fax:608-785-6561
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI613-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer