Provider Demographics
NPI:1457937526
Name:GBALA, TAYONON E (LMT,OMT)
Entity Type:Individual
Prefix:MRS
First Name:TAYONON
Middle Name:E
Last Name:GBALA
Suffix:
Gender:F
Credentials:LMT,OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 S AUSTIN BLVD APT 2S
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2369
Mailing Address - Country:US
Mailing Address - Phone:708-205-2363
Mailing Address - Fax:
Practice Address - Street 1:918 S AUSTIN BLVD APT 2S
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2369
Practice Address - Country:US
Practice Address - Phone:708-205-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227003033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist