Provider Demographics
NPI:1912242587
Name:NGUYEN, GLADY
Entity Type:Individual
Prefix:
First Name:GLADY
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLADY
Other - Middle Name:
Other - Last Name:DOMANAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3107 BIRCH RUN
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1134
Mailing Address - Country:US
Mailing Address - Phone:517-264-5078
Mailing Address - Fax:
Practice Address - Street 1:1231 HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1471
Practice Address - Country:US
Practice Address - Phone:313-492-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist