Provider Demographics
NPI:1992068027
Name:GANSON, MARCIE L (PT, DPT, MBA)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:L
Last Name:GANSON
Suffix:
Gender:F
Credentials:PT, DPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N PROMENADE ST
Mailing Address - Street 2:PO BOX 530
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1243
Mailing Address - Country:US
Mailing Address - Phone:309-543-8578
Mailing Address - Fax:309-543-8571
Practice Address - Street 1:615 N PROMENADE ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644-1243
Practice Address - Country:US
Practice Address - Phone:309-543-8578
Practice Address - Fax:309-543-8571
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist