Provider Demographics
NPI:1619637808
Name:ANDES, GREGORY ELLIS JR
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ELLIS
Last Name:ANDES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 WINDY HILL LN
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8533
Mailing Address - Country:US
Mailing Address - Phone:567-204-9564
Mailing Address - Fax:
Practice Address - Street 1:814 WINDY HILL LN
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8533
Practice Address - Country:US
Practice Address - Phone:567-204-9564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA011019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty