Provider Demographics
NPI:1669773974
Name:DOCKUM, GINGER (PTA)
Entity type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:DOCKUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05150-9200
Mailing Address - Country:US
Mailing Address - Phone:802-952-8604
Mailing Address - Fax:
Practice Address - Street 1:49 CEDAR HILL DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-9470
Practice Address - Country:US
Practice Address - Phone:802-674-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0000540225200000X
NH0706225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant