Provider Demographics
NPI:1538447594
Name:SKELLY, GREGORY EDWARD (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:EDWARD
Last Name:SKELLY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 COUGAR DR
Mailing Address - Street 2:APT B
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2926
Mailing Address - Country:US
Mailing Address - Phone:618-559-1013
Mailing Address - Fax:
Practice Address - Street 1:2086 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5631
Practice Address - Country:US
Practice Address - Phone:618-288-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.018626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist