Provider Demographics
NPI:1841470515
Name:GUPTILL, TERRY LEROY (PT,ATC)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEROY
Last Name:GUPTILL
Suffix:
Gender:M
Credentials:PT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 11 STREET
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2490
Mailing Address - Country:US
Mailing Address - Phone:509-758-2523
Mailing Address - Fax:509-295-2952
Practice Address - Street 1:1242 11TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2815
Practice Address - Country:US
Practice Address - Phone:509-758-2523
Practice Address - Fax:509-295-2952
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008222225100000X
IDPT1541225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer