Provider Demographics
NPI:1639553837
Name:WAKEFIELD, GREG (ATC, SCAT)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CATAWBA CIR APT 923
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-5266
Mailing Address - Country:US
Mailing Address - Phone:208-309-2991
Mailing Address - Fax:
Practice Address - Street 1:1 CATAWBA CIR APT 923
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-5266
Practice Address - Country:US
Practice Address - Phone:208-309-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer