Healthcare Provider Details

I. General information

NPI: 1477718195
Provider Name (Legal Business Name): GREGORY LYNN STRICKLAND PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WINDY HILL DR
LAFAYETTE IN
47905-2862
US

IV. Provider business mailing address

300 WINDY HILL DR
LAFAYETTE IN
47905-2862
US

V. Phone/Fax

Practice location:
  • Phone: 765-477-7791
  • Fax: 765-474-2986
Mailing address:
  • Phone: 765-477-7791
  • Fax: 765-474-2986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06003444A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1356
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: