Provider Demographics
NPI:1164931531
Name:RYAN, GREGORY (DPT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LIBERTY SQ
Mailing Address - Street 2:BSMT 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5814
Mailing Address - Country:US
Mailing Address - Phone:617-536-1161
Mailing Address - Fax:857-239-9711
Practice Address - Street 1:348 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1197
Practice Address - Country:US
Practice Address - Phone:508-897-0056
Practice Address - Fax:508-584-5360
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23223225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist