Provider Demographics
NPI:1902825672
Name:GILLIAM, KARL ERIC FORSBERG (MSPT,CSCS,CI)
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:ERIC FORSBERG
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MSPT,CSCS,CI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 RUE LABEAU CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7513
Mailing Address - Country:US
Mailing Address - Phone:239-369-0777
Mailing Address - Fax:
Practice Address - Street 1:12670 CREEKSIDE LN
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3359
Practice Address - Country:US
Practice Address - Phone:239-267-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1902825672OtherCIGNA