Provider Demographics
NPI:1962774752
Name:GAMM, SHEILA DIANE (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:DIANE
Last Name:GAMM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2414
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-2414
Mailing Address - Country:US
Mailing Address - Phone:573-280-2000
Mailing Address - Fax:
Practice Address - Street 1:25023 BOTHWELL PARK RD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-0084
Practice Address - Country:US
Practice Address - Phone:573-826-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011036406225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant