Provider Demographics
NPI:1083623177
Name:GREGORY, TIMOTHY RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:GREGORY
Suffix:
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:PO BOX 3159
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-0257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2415
Practice Address - Country:US
Practice Address - Phone:845-858-3253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0430531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
475049000OtherMAGELLEN
1032020OtherAFFINITY HEALTH PLAN
N63253OtherEMPIRE BLUE CROSS/SHIELD
N63253OtherBLUE CROSS BLUE SHIELD
YS112OtherOXFORD HEALTH PLANS
164055OtherVALUEOPTIONS
1032020OtherHUDSON HEALTH PLAN
1032020OtherBEACON HEALTH STRATEGIES
7406375003OtherGHI
N63252OtherEMPIRE BLUE CROSS/SHIELD
0007782292OtherAETNA
N63252OtherBLUE CROSS BLUE SHIELD
N63251Medicare ID - Type Unspecified