Provider Demographics
NPI:1215136239
Name:GABASA, NICK V JR
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:V
Last Name:GABASA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 S COUNTRY CLUB RD APT 210
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4439
Mailing Address - Country:US
Mailing Address - Phone:586-344-1682
Mailing Address - Fax:
Practice Address - Street 1:444 W HARRISON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4157
Practice Address - Country:US
Practice Address - Phone:217-877-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist