Provider Demographics
NPI:1972840171
Name:GUMMA, SIREESHA (MPT)
Entity type:Individual
Prefix:MRS
First Name:SIREESHA
Middle Name:
Last Name:GUMMA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MERCY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9597
Mailing Address - Country:US
Mailing Address - Phone:309-268-1501
Mailing Address - Fax:
Practice Address - Street 1:1223 BLUE BILL WAY
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9400
Practice Address - Country:US
Practice Address - Phone:309-282-4886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist