Provider Demographics
NPI:1851906887
Name:GILDERSLEEVE, TEDDY RAY
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:RAY
Last Name:GILDERSLEEVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37320 ORIOLE AVE
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9109
Mailing Address - Country:US
Mailing Address - Phone:715-501-0047
Mailing Address - Fax:
Practice Address - Street 1:37320 ORIOLE AVE
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9109
Practice Address - Country:US
Practice Address - Phone:715-501-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer