Provider Demographics
NPI:1629844881
Name:BALASANYAN, GRIGOR GREG (PT, DPT)
Entity type:Individual
Prefix:
First Name:GRIGOR
Middle Name:GREG
Last Name:BALASANYAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12410 BURBANK BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-4728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12410 BURBANK BLVD STE 103
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-4728
Practice Address - Country:US
Practice Address - Phone:818-804-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist