Provider Demographics
NPI:1770017618
Name:PENNY, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:PENNY
Suffix:
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 1:6501 RED HOOK PLZ
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802-1373
Mailing Address - Country:US
Mailing Address - Phone:405-821-3077
Mailing Address - Fax:
Practice Address - Street 1:6555 NW 9TH AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2067
Practice Address - Country:US
Practice Address - Phone:954-771-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist