Provider Demographics
NPI:1720086549
Name:GRIECO, LEONARD A (PT)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:A
Last Name:GRIECO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16,LL
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-480-7100
Mailing Address - Fax:814-480-7604
Practice Address - Street 1:TRAC REHAB PEACH
Practice Address - Street 2:5100 PEACH STREET
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509
Practice Address - Country:US
Practice Address - Phone:814-864-5097
Practice Address - Fax:814-864-9583
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000355E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016785750006Medicaid
PA3110682OtherAETNA
NY00025600602OtherUNIVERA
PA669114OtherBLUE SHIELD
PAP00111335OtherRR MEDICARE
PAP00111335OtherRR MEDICARE
PA0016785750006Medicaid