Provider Demographics
NPI:1659417566
Name:ST. ROMAIN, GWENDOLYN (PT)
Entity Type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:
Last Name:ST. ROMAIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1799 STUMPF BLVD
Mailing Address - Street 2:BLDG 1, SUITE 4
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:504-365-1020
Mailing Address - Fax:504-365-1080
Practice Address - Street 1:1799 STUMPF BLVD
Practice Address - Street 2:BUILDING 1, SUITE 4
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:504-365-1020
Practice Address - Fax:504-365-1080
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00558OtherPT LICENSE #