Provider Demographics
NPI:1164689436
Name:COURCELLE, GINA THERESA (PT)
Entity type:Individual
Prefix:MISS
First Name:GINA
Middle Name:THERESA
Last Name:COURCELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:LUCARINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5 ALBERT CREE DR
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4601
Mailing Address - Country:US
Mailing Address - Phone:802-775-1300
Mailing Address - Fax:802-773-9300
Practice Address - Street 1:5 ALBERT CREE DR
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4601
Practice Address - Country:US
Practice Address - Phone:802-775-1300
Practice Address - Fax:802-773-9300
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008318225100000X
VT0400097034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002058Medicaid
650001594Medicare UPIN