Provider Demographics
NPI:1619394806
Name:GAMBLE, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GAMBLE
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 1:6815 MANHATTAN BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-1204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6815 MANHATTAN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1204
Practice Address - Country:US
Practice Address - Phone:817-507-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2067862225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant