Healthcare Provider Details

I. General information

NPI: 1104800655
Provider Name (Legal Business Name): GREGORY STUART SYVERTSON PT, DPT, CFT,CCI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GREG S SYVERTSON PT, DPT, CFT,CCI

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JOHN RAINE DR
RAINELLE WV
25962-1457
US

IV. Provider business mailing address

PO BOX 767
DANIELS WV
25832-0767
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-9225
  • Fax: 304-438-9226
Mailing address:
  • Phone: 304-252-4170
  • Fax: 304-252-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0001489
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: