Provider Demographics
NPI:1508460593
Name:GILMORE, BETHEL (PTA)
Entity Type:Individual
Prefix:
First Name:BETHEL
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-0849
Mailing Address - Country:US
Mailing Address - Phone:337-824-8287
Mailing Address - Fax:337-824-8290
Practice Address - Street 1:204 E SAINT PETER ST
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4009
Practice Address - Country:US
Practice Address - Phone:337-896-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA1939R225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant