Provider Demographics
NPI:1205800901
Name:GREGG, MICHAEL D (MSPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GREGG
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:1129 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4100
Practice Address - Country:US
Practice Address - Phone:509-527-8928
Practice Address - Fax:509-527-8929
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA133822OtherL&I
WA8373151Medicaid
OR040118Medicaid
WAGAB13309Medicare PIN
OR040118Medicaid