Provider Demographics
NPI:1093496804
Name:MICKLES, GREGORY A
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:MICKLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 HUNTER PLACE SOUTHEAST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020
Mailing Address - Country:US
Mailing Address - Phone:120-271-0283
Mailing Address - Fax:
Practice Address - Street 1:3029 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2506
Practice Address - Country:US
Practice Address - Phone:202-232-6100
Practice Address - Fax:202-610-9507
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator