Provider Demographics
NPI:1780149914
Name:HARRISON, GINA MARIA (PTA)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIA
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:GINA
Other - Middle Name:MARIA
Other - Last Name:DIMEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 DEER HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1486
Mailing Address - Country:US
Mailing Address - Phone:781-254-4431
Mailing Address - Fax:
Practice Address - Street 1:62 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1005
Practice Address - Country:US
Practice Address - Phone:339-883-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6323225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
6323OtherMA BOARD OF LICENSURE