Provider Demographics
NPI:1316374614
Name:GILDEA, MARY KATE (DPT)
Entity type:Individual
Prefix:
First Name:MARY KATE
Middle Name:
Last Name:GILDEA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9115
Practice Address - Country:US
Practice Address - Phone:304-842-4135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist