Provider Demographics
NPI:1144781097
Name:GREGORY, TAMIKA DAVETTE
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:DAVETTE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMIKA
Other - Middle Name:
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ALC
Mailing Address - Street 1:8119 GREENVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LUVERNE
Mailing Address - State:AL
Mailing Address - Zip Code:36049-6481
Mailing Address - Country:US
Mailing Address - Phone:334-391-9595
Mailing Address - Fax:
Practice Address - Street 1:8119 GREENVILLE HWY
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:AL
Practice Address - Zip Code:36049-6481
Practice Address - Country:US
Practice Address - Phone:334-391-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2038A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health