Provider Demographics
NPI:1093118895
Name:GREGG, EVELYN T (REGISTERED NURSE I)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:T
Last Name:GREGG
Suffix:
Gender:F
Credentials:REGISTERED NURSE I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 STONY LANDING RD
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3967
Mailing Address - Country:US
Mailing Address - Phone:843-761-8282
Mailing Address - Fax:843-761-7308
Practice Address - Street 1:403 STONY LANDING RD
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3967
Practice Address - Country:US
Practice Address - Phone:843-761-8282
Practice Address - Fax:843-761-7308
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRN 38274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC435201Medicaid
SC3348Medicare PIN