Provider Demographics
NPI:1750517900
Name:GEMLICH, GARY DREW (PTA)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:DREW
Last Name:GEMLICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-7974
Mailing Address - Country:US
Mailing Address - Phone:304-692-8074
Mailing Address - Fax:
Practice Address - Street 1:161 BAKERS RIDGE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1459
Practice Address - Country:US
Practice Address - Phone:304-285-0692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001430225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant