Healthcare Provider Details

I. General information

NPI: 1053373787
Provider Name (Legal Business Name): GREGG W CONDON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 WILLIMANSETT ST
SOUTH HADLEY MA
01075-3062
US

IV. Provider business mailing address

65 SPRINGFIELD RD
WESTFIELD MA
01085-1855
US

V. Phone/Fax

Practice location:
  • Phone: 413-533-8501
  • Fax: 413-533-8502
Mailing address:
  • Phone: 413-568-1388
  • Fax: 413-568-1389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10722
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: