Provider Demographics
NPI:1154173797
Name:GALLANT, THERESA MARIE (RPT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:GALLANT
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 N PEPPER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1930
Mailing Address - Country:US
Mailing Address - Phone:316-519-6398
Mailing Address - Fax:
Practice Address - Street 1:777 N MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4980
Practice Address - Country:US
Practice Address - Phone:316-942-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-030112251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics