Provider Demographics
NPI:1457405722
Name:MOTAVALLI, GERTRUD ELISABET
Entity Type:Individual
Prefix:
First Name:GERTRUD
Middle Name:ELISABET
Last Name:MOTAVALLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GERTI
Other - Middle Name:ELISABET
Other - Last Name:MOTAVALLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:4002 W BAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5871
Mailing Address - Country:US
Mailing Address - Phone:573-447-4304
Mailing Address - Fax:
Practice Address - Street 1:4002 W BAYWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5871
Practice Address - Country:US
Practice Address - Phone:573-447-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist