Provider Demographics
NPI:1174994354
Name:GAVIN, KERRILYN (PT, DPT, MTC)
Entity type:Individual
Prefix:
First Name:KERRILYN
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:PT, DPT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 SONYA ST
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9554
Mailing Address - Country:US
Mailing Address - Phone:850-529-3496
Mailing Address - Fax:
Practice Address - Street 1:3355 COPTER RD BLDG 1&2
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-7083
Practice Address - Country:US
Practice Address - Phone:850-529-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT120622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic