Provider Demographics
NPI:1093938722
Name:PEMBERTON, GREGORY A (RPT AND OTR)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:PEMBERTON
Suffix:
Gender:
Credentials:RPT AND OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2253 ALLEGHENY LANE
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-8347
Mailing Address - Country:US
Mailing Address - Phone:678-753-1135
Mailing Address - Fax:678-753-1173
Practice Address - Street 1:2253 ALLEGHENY LANE
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-8347
Practice Address - Country:US
Practice Address - Phone:678-753-1135
Practice Address - Fax:678-753-1173
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000620225X00000X
GAPT002327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000692546BMedicaid
GA000692546CMedicaid