Provider Demographics
NPI:1558194563
Name:EDBERG, GREY (PT)
Entity type:Individual
Prefix:
First Name:GREY
Middle Name:
Last Name:EDBERG
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 1:107 FIRSTPARK
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963
Mailing Address - Country:US
Mailing Address - Phone:207-873-8140
Mailing Address - Fax:207-873-8141
Practice Address - Street 1:107 FIRSTPARK
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963
Practice Address - Country:US
Practice Address - Phone:207-873-8140
Practice Address - Fax:207-873-8141
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT6945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist