Provider Demographics
NPI:1073744801
Name:CRECELIUS, GREGORY J (PTA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:CRECELIUS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BLANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45107-1310
Mailing Address - Country:US
Mailing Address - Phone:937-783-3874
Mailing Address - Fax:937-783-4951
Practice Address - Street 1:820 E CENTER ST
Practice Address - Street 2:
Practice Address - City:BLANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45107-1310
Practice Address - Country:US
Practice Address - Phone:937-783-3874
Practice Address - Fax:937-783-4951
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA. 02748225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant