Provider Demographics
NPI:1689482358
Name:ROBERTS, GREGORY (CMT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HICKEY BLVD
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-1446
Mailing Address - Country:US
Mailing Address - Phone:415-533-0009
Mailing Address - Fax:
Practice Address - Street 1:862 FOLSOM ST STE 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-1123
Practice Address - Country:US
Practice Address - Phone:415-533-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90659225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist