Provider Demographics
NPI:1073672275
Name:WIGHTMAN, GREGORY JOHN (LPCC SUPV)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOHN
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:LPCC SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E BROAD ST
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3414
Mailing Address - Country:US
Mailing Address - Phone:614-466-6583
Mailing Address - Fax:614-995-3268
Practice Address - Street 1:2611 WAYNE AVE
Practice Address - Street 2:BUILDING #66
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1833
Practice Address - Country:US
Practice Address - Phone:937-258-0440
Practice Address - Fax:937-258-6235
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000394 SUPV101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor