Provider Demographics
NPI:1902901879
Name:GULSRUD-NEIBER, LORI L (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:GULSRUD-NEIBER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1686 HENRY LUCKOW LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1705
Mailing Address - Country:US
Mailing Address - Phone:815-547-4777
Mailing Address - Fax:815-547-1024
Practice Address - Street 1:1686 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1705
Practice Address - Country:US
Practice Address - Phone:815-547-4777
Practice Address - Fax:815-547-1024
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-008204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20025ILOtherMEDICARE PTAN