Provider Demographics
NPI:1043966591
Name:SPEZIALE, GREG
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:SPEZIALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PARK AVE UNIT 682941
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-4619
Mailing Address - Country:US
Mailing Address - Phone:801-425-8767
Mailing Address - Fax:
Practice Address - Street 1:36 RACQUET CLUB DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:801-425-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1478175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1478OtherSTATE OF UTAH CERTIFIED PEER SUPPORT SPECIALIST