Provider Demographics
NPI:1164663282
Name:GRESHAM, LORETTA M (PT)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:M
Last Name:GRESHAM
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 1:1419 PINE VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-2632
Mailing Address - Country:US
Mailing Address - Phone:501-663-2189
Mailing Address - Fax:
Practice Address - Street 1:810 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-1306
Practice Address - Country:US
Practice Address - Phone:501-447-1000
Practice Address - Fax:501-447-1001
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics