Provider Demographics
NPI:1609097682
Name:GAINES, LAURA (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GAINES
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:ROUTE 1 BOX 149
Mailing Address - Street 2:
Mailing Address - City:SCHELL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64783
Mailing Address - Country:US
Mailing Address - Phone:417-432-3537
Mailing Address - Fax:
Practice Address - Street 1:103 E NURSERY
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:MO
Practice Address - Zip Code:64730-9309
Practice Address - Country:US
Practice Address - Phone:660-679-3179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115388225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant