Provider Demographics
NPI:1386686244
Name:PETTY, GREGORY WAYNE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WAYNE
Last Name:PETTY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:14114 ALABAMA STREET
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565
Mailing Address - Country:US
Mailing Address - Phone:850-675-8040
Mailing Address - Fax:850-675-8016
Practice Address - Street 1:2071 S ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36460-8681
Practice Address - Country:US
Practice Address - Phone:251-575-1933
Practice Address - Fax:251-575-2807
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL2257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-33361OtherBLUE CROSS
AL515-33361OtherBLUE CROSS