Provider Demographics
NPI:1689090029
Name:PENCZEK, GREGORY (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PENCZEK
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 YORK RD
Mailing Address - Street 2:FIELD HOUSE 101
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21252-0001
Mailing Address - Country:US
Mailing Address - Phone:410-704-2890
Mailing Address - Fax:410-704-2727
Practice Address - Street 1:8000 YORK RD
Practice Address - Street 2:FIELD HOUSE 101
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-2890
Practice Address - Fax:410-704-2727
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00000712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer