Provider Demographics
NPI:1457881161
Name:GAVIN, ELLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9219
Mailing Address - Country:US
Mailing Address - Phone:304-263-5680
Mailing Address - Fax:
Practice Address - Street 1:208 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9219
Practice Address - Country:US
Practice Address - Phone:304-263-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26507225100000X
WVPT004264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD26507OtherMARYLAND BOARD OF PHYSICAL THERAPY