Provider Demographics
NPI:1245284207
Name:BELISLE, GWENDOLYN (MSPT)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:BELISLE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:WENDI
Other - Middle Name:
Other - Last Name:VANHOUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 241686
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-1686
Mailing Address - Country:US
Mailing Address - Phone:334-396-2115
Mailing Address - Fax:334-396-2115
Practice Address - Street 1:825 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-1847
Practice Address - Country:US
Practice Address - Phone:334-688-7155
Practice Address - Fax:334-616-7615
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist