Provider Demographics
NPI:1609419480
Name:GORRELL, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:GORRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14240 BULL RAPIDS RD
Mailing Address - Street 2:
Mailing Address - City:GRABILL
Mailing Address - State:IN
Mailing Address - Zip Code:46741-9623
Mailing Address - Country:US
Mailing Address - Phone:260-466-0127
Mailing Address - Fax:
Practice Address - Street 1:725 6TH ST STE 101
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2006
Practice Address - Country:US
Practice Address - Phone:509-758-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013527A225100000X
UT11435288-2401225100000X
WAPT61002252225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist