Provider Demographics
NPI:1891912101
Name:GUBAN, WILMA (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:
Last Name:GUBAN
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MANSFIELD PL
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4149
Mailing Address - Country:US
Mailing Address - Phone:802-773-6698
Mailing Address - Fax:
Practice Address - Street 1:9 HAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4832
Practice Address - Country:US
Practice Address - Phone:802-747-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003617225100000X
FL15440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist