Provider Demographics
NPI:1194898288
Name:GWILLIM, LAURA D
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:GWILLIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2924
Mailing Address - Country:US
Mailing Address - Phone:229-251-0372
Mailing Address - Fax:
Practice Address - Street 1:2704 C N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1781
Practice Address - Country:US
Practice Address - Phone:229-245-0646
Practice Address - Fax:229-245-8946
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSN94E177Medicare ID - Type UnspecifiedDEAVER