Provider Demographics
NPI:1063544534
Name:GRELLA, RYAN J (PT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:GRELLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 STARBOARD KY
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-2861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1395 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3790
Practice Address - Country:US
Practice Address - Phone:727-942-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist