Provider Demographics
NPI:1730430570
Name:BEHROUZI, GISOU (RPT, DPT)
Entity type:Individual
Prefix:DR
First Name:GISOU
Middle Name:
Last Name:BEHROUZI
Suffix:
Gender:F
Credentials:RPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-3405
Mailing Address - Country:US
Mailing Address - Phone:574-850-8710
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-886-4677
Practice Address - Fax:812-886-4678
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005665A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist