Provider Demographics
NPI:1093498958
Name:QUACKENBUSH, GREGG MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:MICHAEL
Last Name:QUACKENBUSH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:LEONARDO
Mailing Address - State:NJ
Mailing Address - Zip Code:07737-1121
Mailing Address - Country:US
Mailing Address - Phone:732-320-2251
Mailing Address - Fax:
Practice Address - Street 1:350 W SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-5663
Practice Address - Country:US
Practice Address - Phone:908-925-6797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02194900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist