Provider Demographics
NPI:1063863629
Name:OBERT, GREGORY (PHD, LCPC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:OBERT
Suffix:
Gender:M
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7570 OLD CANTON RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6100
Mailing Address - Country:US
Mailing Address - Phone:601-809-5324
Mailing Address - Fax:
Practice Address - Street 1:7570 OLD CANTON RD STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6100
Practice Address - Country:US
Practice Address - Phone:601-809-5324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180013378101YM0800X
MS641183103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health