Healthcare Provider Details

I. General information

NPI: 1356037139
Provider Name (Legal Business Name): GREGORY STEPHEN ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5803 W NORTHERN AVE STE 110
GLENDALE AZ
85301-1737
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-3699
  • Fax: 623-322-0654
Mailing address:
  • Phone: 866-370-8206
  • Fax: 517-435-3670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-32871
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: