Provider Demographics
NPI:1578775904
Name:GONTKOF, LAUREN MELISSA (MED, ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MELISSA
Last Name:GONTKOF
Suffix:
Gender:F
Credentials:MED, ATC, LAT
Other - Prefix:MRS
Other - First Name:LAUREN
Other - Middle Name:MELISSA
Other - Last Name:RUPPERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, ATC, LAT
Mailing Address - Street 1:1912 HARBOUR DR
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-3320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1912 HARBOUR DR
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:TX
Practice Address - Zip Code:77586-3320
Practice Address - Country:US
Practice Address - Phone:713-470-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT36422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer