Provider Demographics
NPI:1609298173
Name:GAYLON, MARESTELA
Entity Type:Individual
Prefix:
First Name:MARESTELA
Middle Name:
Last Name:GAYLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 BERKMAN CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6311
Mailing Address - Country:US
Mailing Address - Phone:321-578-2415
Mailing Address - Fax:
Practice Address - Street 1:12124 HIGH TECH AVE STE 300
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8374
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist