Provider Demographics
NPI:1588739908
Name:PROCTOR, GRETCHEN E (OTR/CHT)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:E
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:OTR/CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:108 BILBY RD STE 201
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-4174
Practice Address - Country:US
Practice Address - Phone:908-684-5646
Practice Address - Fax:908-684-5649
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00032700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ069654TTOMedicare ID - Type Unspecified