Provider Demographics
NPI:1245578301
Name:GREGORY, GARY STEVENS SR (LMT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:STEVENS
Last Name:GREGORY
Suffix:SR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 BORDEN RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4207
Mailing Address - Country:US
Mailing Address - Phone:716-698-4120
Mailing Address - Fax:
Practice Address - Street 1:326 CAYUGA RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-1940
Practice Address - Country:US
Practice Address - Phone:716-632-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025710173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
025710OtherLICENSE MASSAGE THERAPIST