Provider Demographics
NPI:1063487973
Name:LETOURNEAU, GREGORY IX (LCSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LETOURNEAU
Suffix:IX
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2517
Mailing Address - Country:US
Mailing Address - Phone:336-750-0130
Mailing Address - Fax:336-750-0073
Practice Address - Street 1:915 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2517
Practice Address - Country:US
Practice Address - Phone:336-750-0130
Practice Address - Fax:336-750-0073
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0036331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13809OtherBLUECROSSBLUESHEILD
NC6003585Medicaid