Provider Demographics
NPI:1649245192
Name:GAULT, TERRY L (MA, ATC, LAT)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:GAULT
Suffix:
Gender:M
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26403 BUBBLING BRK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-5346
Mailing Address - Country:US
Mailing Address - Phone:830-980-8932
Mailing Address - Fax:
Practice Address - Street 1:1 GREYHOUND LN
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-1810
Practice Address - Country:US
Practice Address - Phone:830-357-2287
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT14482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer