Provider Demographics
NPI:1548325905
Name:HOMER, GWEN S (PT)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:S
Last Name:HOMER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:S
Other - Last Name:KOEKERITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1402 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1604
Mailing Address - Country:US
Mailing Address - Phone:605-941-1178
Mailing Address - Fax:844-912-2555
Practice Address - Street 1:1402 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1604
Practice Address - Country:US
Practice Address - Phone:605-941-1178
Practice Address - Fax:844-912-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5834562Medicaid