Provider Demographics
NPI:1497369466
Name:GORHAM, OLIVIA CLAIRE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CLAIRE
Last Name:GORHAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 LANGDALE LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-5510
Mailing Address - Country:US
Mailing Address - Phone:832-797-2131
Mailing Address - Fax:
Practice Address - Street 1:4402 WILLIAMS DR STE 115
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1388
Practice Address - Country:US
Practice Address - Phone:512-256-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13356322251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1335632OtherPHYSICAL THERAPY LICENSE NUMBER