Provider Demographics
NPI:1871835827
Name:DEBORD, GABRIEL (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:DEBORD
Suffix:
Gender:M
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1317
Practice Address - Country:US
Practice Address - Phone:419-349-2821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-17
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.010013172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist