Provider Demographics
NPI:1831788058
Name:MURDOCK, GREGORY WAYLON (COTA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYLON
Last Name:MURDOCK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17116 HARPERS TRCE APT 3310
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-1153
Mailing Address - Country:US
Mailing Address - Phone:936-553-4440
Mailing Address - Fax:
Practice Address - Street 1:17116 HARPERS TRCE APT 3310
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-1153
Practice Address - Country:US
Practice Address - Phone:936-553-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215307224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant