Provider Demographics
NPI:1023778644
Name:GINGERY, GAELYN R
Entity type:Individual
Prefix:
First Name:GAELYN
Middle Name:R
Last Name:GINGERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130A N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2053
Mailing Address - Country:US
Mailing Address - Phone:773-742-4804
Mailing Address - Fax:
Practice Address - Street 1:1300 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4415
Practice Address - Country:US
Practice Address - Phone:414-228-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI580727224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant