Provider Demographics
NPI:1215473608
Name:GREGORY, KORTNEY (PT)
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KORTNEY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3379 LUM RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-8342
Mailing Address - Country:US
Mailing Address - Phone:810-310-0984
Mailing Address - Fax:
Practice Address - Street 1:1739 N SAGINAW ST STE 103
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-7627
Practice Address - Country:US
Practice Address - Phone:810-660-7754
Practice Address - Fax:810-660-8254
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist