Provider Demographics
NPI:1770266785
Name:GREGORY, OLIVIA SANDERSON (DPT)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:SANDERSON
Last Name:GREGORY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2300
Mailing Address - Country:US
Mailing Address - Phone:901-522-7700
Mailing Address - Fax:901-522-2600
Practice Address - Street 1:391 SOUTHCREST CIR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6730
Practice Address - Country:US
Practice Address - Phone:091-522-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15300225100000X
MSPT7612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200006016Medicaid
TNQ088576Medicaid