Provider Demographics
NPI:1750321071
Name:SCHNEIDER, GARY DOUGLAS (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DOUGLAS
Last Name:SCHNEIDER
Suffix:
Gender:M
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:PO BOX 3115
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-3115
Mailing Address - Country:US
Mailing Address - Phone:208-772-8147
Mailing Address - Fax:208-762-2625
Practice Address - Street 1:8257 N CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8683
Practice Address - Country:US
Practice Address - Phone:208-772-0881
Practice Address - Fax:208-762-2625
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist