Provider Demographics
NPI:1972684611
Name:REINOSO, JOSEPHINE GALLARDO (RPT)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:GALLARDO
Last Name:REINOSO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:ABAYON
Other - Last Name:GALLARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPT
Mailing Address - Street 1:PO BOX 99671
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099
Mailing Address - Country:US
Mailing Address - Phone:313-873-6220
Mailing Address - Fax:313-873-6788
Practice Address - Street 1:9427 CONANT ST
Practice Address - Street 2:SUITE C
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-873-6220
Practice Address - Fax:313-873-6788
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P56790Medicare PIN