Provider Demographics
NPI:1184090458
Name:ANDERSON, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ANDERSON
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 1:162 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2061
Mailing Address - Country:US
Mailing Address - Phone:860-456-2232
Mailing Address - Fax:860-456-2256
Practice Address - Street 1:162 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2061
Practice Address - Country:US
Practice Address - Phone:860-264-1940
Practice Address - Fax:605-301-8508
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY039000225100000X
CT11176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN