Provider Demographics
NPI:1588280200
Name:GAYFORD, KATY RENEE (ATC, PHD)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:RENEE
Last Name:GAYFORD
Suffix:
Gender:F
Credentials:ATC, PHD
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:RENEE
Other - Last Name:TAAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:701 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1291
Mailing Address - Country:US
Mailing Address - Phone:618-537-6472
Mailing Address - Fax:
Practice Address - Street 1:701 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1291
Practice Address - Country:US
Practice Address - Phone:618-537-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960016982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer