Provider Demographics
NPI:1720524796
Name:GILLIN, ALTA REBEKAH (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:ALTA
Middle Name:REBEKAH
Last Name:GILLIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 CRAIN HWY S STE 110
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4086
Mailing Address - Country:US
Mailing Address - Phone:410-762-2124
Mailing Address - Fax:410-705-5057
Practice Address - Street 1:1406 CRAIN HWY S STE 110
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-762-2124
Practice Address - Fax:410-705-5057
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2018-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist