Provider Demographics
NPI:1972329670
Name:CREEL, GAGE BRENDAN (PTA)
Entity type:Individual
Prefix:
First Name:GAGE
Middle Name:BRENDAN
Last Name:CREEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 FULTON RD
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427-4090
Mailing Address - Country:US
Mailing Address - Phone:304-886-8736
Mailing Address - Fax:
Practice Address - Street 1:13857 APPLE HARVEST DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-6199
Practice Address - Country:US
Practice Address - Phone:304-596-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003004225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant