Provider Demographics
NPI:1124066956
Name:SIMONS, GWENDOLYN JANE (PT,JD,OCS,FAAOMPT)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:JANE
Last Name:SIMONS
Suffix:
Gender:F
Credentials:PT,JD,OCS,FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-3606
Mailing Address - Country:US
Mailing Address - Phone:207-324-6789
Mailing Address - Fax:207-324-9394
Practice Address - Street 1:1068 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3606
Practice Address - Country:US
Practice Address - Phone:207-324-6789
Practice Address - Fax:207-324-9394
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT27272251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME326960099Medicaid
1467488890OtherANTHEM
1467488890OtherHARVARD PILGRIMI
ME2041Medicare PIN