Provider Demographics
NPI:1043781214
Name:BERUBE, GINA MARIA (PT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIA
Last Name:BERUBE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 TAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-2809
Mailing Address - Country:US
Mailing Address - Phone:410-474-6200
Mailing Address - Fax:
Practice Address - Street 1:3760 TAYLOR LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-2809
Practice Address - Country:US
Practice Address - Phone:410-474-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist