Provider Demographics
NPI:1093938722
Name:PEMBERTON, GREGORY A (RPT AND OTR)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:RPT AND OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 ALLEGHENY LANE
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-8347
Mailing Address - Country:US
Mailing Address - Phone:678-753-1135
Mailing Address - Fax:678-753-1173
Practice Address - Street 1:2253 ALLEGHENY LANE
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-8347
Practice Address - Country:US
Practice Address - Phone:678-753-1135
Practice Address - Fax:678-753-1173
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002327225100000X
GAOT000620225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist