Provider Demographics
NPI:1033273651
Name:GREGORISCH, ERIC (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GREGORISCH
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 W KENNEDY BLVD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2719
Mailing Address - Country:US
Mailing Address - Phone:813-350-9490
Mailing Address - Fax:813-877-3839
Practice Address - Street 1:3839 W KENNEDY BLVD
Practice Address - Street 2:SUITE ONE
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2719
Practice Address - Country:US
Practice Address - Phone:813-350-9490
Practice Address - Fax:813-877-3839
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1697106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT1697OtherMARRIAGE COUNSELOR
FL767457100Medicaid