Provider Demographics
NPI:1851301311
Name:NEILSEN, GREGORY BRET (MPT)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:BRET
Last Name:NEILSEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PORTION RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-588-2100
Mailing Address - Fax:631-588-2299
Practice Address - Street 1:500 PORTION RD
Practice Address - Street 2:SUITE 5
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779
Practice Address - Country:US
Practice Address - Phone:631-588-2100
Practice Address - Fax:631-588-2299
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP1701Medicare ID - Type Unspecified