Provider Demographics
NPI:1841623071
Name:MYDLO, GINA MARIE (DPT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:MYDLO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:GATTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:932 KYLEMORE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7934
Mailing Address - Country:US
Mailing Address - Phone:636-288-2198
Mailing Address - Fax:
Practice Address - Street 1:932 KYLEMORE DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7934
Practice Address - Country:US
Practice Address - Phone:636-288-2198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO213028599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist