Provider Demographics
NPI:1780239103
Name:GREENWELL, JOSHUA ROSS (DPT)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ROSS
Last Name:GREENWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 BENNETT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-4906
Mailing Address - Country:US
Mailing Address - Phone:208-678-1191
Mailing Address - Fax:
Practice Address - Street 1:1263 BENNETT AVE STE 2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-4906
Practice Address - Country:US
Practice Address - Phone:208-678-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist