Provider Demographics
NPI:1962260836
Name:WATNICK, GAIL (PT)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:WATNICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 NE 122ND AVE BLDG 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1049
Mailing Address - Country:US
Mailing Address - Phone:503-803-0569
Mailing Address - Fax:
Practice Address - Street 1:4900 NE 122ND AVE BLDG 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1049
Practice Address - Country:US
Practice Address - Phone:503-803-0569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist