Provider Demographics
NPI:1972718393
Name:POLIDORO-HOVER, GAIL (PTA)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:POLIDORO-HOVER
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 1:94 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-3826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 EAST ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-5319
Practice Address - Country:US
Practice Address - Phone:413-442-0610
Practice Address - Fax:413-442-0689
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2247225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant