Healthcare Provider Details

I. General information

NPI: 1184090458
Provider Name (Legal Business Name): GREGORY ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 BROADWAY ST
COLCHESTER CT
06415-1063
US

IV. Provider business mailing address

PO BOX 417594
BOSTON MA
02241-7594
US

V. Phone/Fax

Practice location:
  • Phone: 959-221-7240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number039000
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11176
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: