Provider Demographics
NPI:1780156380
Name:BACON, GAIL (OTR/L)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 DENISE LN
Mailing Address - Street 2:
Mailing Address - City:HUGHESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20637-2335
Mailing Address - Country:US
Mailing Address - Phone:301-751-2151
Mailing Address - Fax:
Practice Address - Street 1:5980 RADIO STATION RD
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-3337
Practice Address - Country:US
Practice Address - Phone:301-751-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist