Provider Demographics
NPI:1629422712
Name:GAVIN, SHERYL LOIS (PTA)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:LOIS
Last Name:GAVIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHERYL
Other - Middle Name:LOIS
Other - Last Name:GUSTUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:224 W GINTY ST
Mailing Address - Street 2:
Mailing Address - City:CADOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54727-9100
Mailing Address - Country:US
Mailing Address - Phone:715-289-4152
Mailing Address - Fax:
Practice Address - Street 1:206 W PROSPECT ST
Practice Address - Street 2:
Practice Address - City:THORP
Practice Address - State:WI
Practice Address - Zip Code:54771-9303
Practice Address - Country:US
Practice Address - Phone:715-669-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI805-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant