Healthcare Provider Details

I. General information

NPI: 1972649440
Provider Name (Legal Business Name): LAURENCE PAUL GREENBERG PT, MS, M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 POND RD
WEST TISBURY MA
02575-0130
US

IV. Provider business mailing address

PO BOX 130
WEST TISBURY MA
02575-0130
US

V. Phone/Fax

Practice location:
  • Phone: 508-696-9171
  • Fax: 508-696-0770
Mailing address:
  • Phone: 508-696-9171
  • Fax: 508-696-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberAH 3703-PT
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberAH 3703-PT
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: