Healthcare Provider Details

I. General information

NPI: 1386686244
Provider Name (Legal Business Name): GREGORY WAYNE PETTY PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 S ALABAMA AVE
MONROEVILLE AL
36460-8681
US

IV. Provider business mailing address

14114 ALABAMA STREET
JAY FL
32565
US

V. Phone/Fax

Practice location:
  • Phone: 251-575-1933
  • Fax: 251-575-2807
Mailing address:
  • Phone: 850-675-8040
  • Fax: 850-675-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2257
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: