Provider Demographics
NPI:1669925061
Name:BASMAJIAN, GREGORY (MBA,ATC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BASMAJIAN
Suffix:
Gender:M
Credentials:MBA,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MICHAEL LN
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-2272
Mailing Address - Country:US
Mailing Address - Phone:978-697-4572
Mailing Address - Fax:
Practice Address - Street 1:120 VASSAR ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4311
Practice Address - Country:US
Practice Address - Phone:978-697-4572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer