Provider Demographics
NPI:1821041179
Name:GYLLENHAAL, DENNIS (PT)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:GYLLENHAAL
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 31630
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1630
Mailing Address - Country:US
Mailing Address - Phone:520-382-8180
Mailing Address - Fax:520-382-8342
Practice Address - Street 1:12315 N VISTOSO PARK RD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-5819
Practice Address - Country:US
Practice Address - Phone:520-382-8180
Practice Address - Fax:520-382-8342
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ336984Medicaid
AZZ212422OtherMEDICARE PTAN
AZ2967OtherPT LICENCE