Provider Demographics
NPI:1104418532
Name:GARGAGLIANO, JOSEPH MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:GARGAGLIANO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19813 CHALON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2201
Mailing Address - Country:US
Mailing Address - Phone:586-216-8046
Mailing Address - Fax:
Practice Address - Street 1:15023 21 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-5024
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006157225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty