Provider Demographics
NPI:1760650964
Name:LEE GASTON, LINDA ANNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANNE
Last Name:LEE GASTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:ANNE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:100 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3720
Mailing Address - Country:US
Mailing Address - Phone:309-242-6730
Mailing Address - Fax:
Practice Address - Street 1:100 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3720
Practice Address - Country:US
Practice Address - Phone:309-242-6730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70009878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist