Provider Demographics
NPI:1700042504
Name:STEWART, GREGGE FORREST (LMT)
Entity Type:Individual
Prefix:MR
First Name:GREGGE
Middle Name:FORREST
Last Name:STEWART
Suffix:
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 1:202 LOQUAT LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4837
Mailing Address - Country:US
Mailing Address - Phone:407-613-6815
Mailing Address - Fax:
Practice Address - Street 1:3959 S NOVA RD STE 35B
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9229
Practice Address - Country:US
Practice Address - Phone:407-613-6815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA15529225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist