Provider Demographics
NPI:1306139209
Name:OHANESSIAN, GREGORY (PT, DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:OHANESSIAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SPRINGFIELD DR.
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132
Mailing Address - Country:US
Mailing Address - Phone:415-420-7623
Mailing Address - Fax:
Practice Address - Street 1:150 PORTOLA RD
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7852
Practice Address - Country:US
Practice Address - Phone:650-851-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA37823225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty