Provider Demographics
NPI:1033543467
Name:GREGSTON, KENNETH THOMAS II
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:THOMAS
Last Name:GREGSTON
Suffix:II
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 1:1483 NARCISSUS CT NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2615
Mailing Address - Country:US
Mailing Address - Phone:503-999-5825
Mailing Address - Fax:
Practice Address - Street 1:1483 NARCISSUS CT NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-2615
Practice Address - Country:US
Practice Address - Phone:503-999-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst