Provider Demographics
NPI:1427756170
Name:GREGORY, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2653
Mailing Address - Country:US
Mailing Address - Phone:304-252-8070
Mailing Address - Fax:304-252-8073
Practice Address - Street 1:314 GEORGE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2653
Practice Address - Country:US
Practice Address - Phone:304-252-8070
Practice Address - Fax:304-252-8073
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001616225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant