Provider Demographics
NPI:1205327053
Name:GUMINO, TERESA (LMT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GUMINO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 OLD BUNCOMBE RD STE 27-213
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-8208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 SMYTHE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3567
Practice Address - Country:US
Practice Address - Phone:864-360-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2018-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist