Provider Demographics
NPI:1760633374
Name:GRIECO, KENNETH GERARD (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GERARD
Last Name:GRIECO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 CHESTNUT TER
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2411
Mailing Address - Country:US
Mailing Address - Phone:201-602-6939
Mailing Address - Fax:
Practice Address - Street 1:172 CHESTNUT TER
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2411
Practice Address - Country:US
Practice Address - Phone:201-602-6939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00524800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist