Provider Demographics
NPI:1760875157
Name:YI, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:YI
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 1:583 CHESTNUT ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY STREET
Practice Address - Street 2:SUITE A24, M/C 6122
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063
Practice Address - Country:US
Practice Address - Phone:650-725-5106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21615225100000X
CA296396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist