Provider Demographics
NPI:1972649440
Name:GREENBERG, LAURENCE PAUL (PT, MS, MED)
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:PAUL
Last Name:GREENBERG
Suffix:
Gender:M
Credentials:PT, MS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-0130
Mailing Address - Country:US
Mailing Address - Phone:508-696-9171
Mailing Address - Fax:508-696-0770
Practice Address - Street 1:170 POND RD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575-0130
Practice Address - Country:US
Practice Address - Phone:508-696-9171
Practice Address - Fax:508-696-0770
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAH 3703-PT2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68244Medicare ID - Type UnspecifiedPHYSICAL THERAPIST