Provider Demographics
NPI:1447961776
Name:LAUDERDALE, GABRIELLE (DPT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:LAUDERDALE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:
Practice Address - Street 1:1400 W GEORGIA RD STE 400
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6970
Practice Address - Country:US
Practice Address - Phone:864-757-3053
Practice Address - Fax:864-920-5122
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist