Provider Demographics
NPI:1174259329
Name:WASHINGTON, GREGORY ANTHONY II
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ANTHONY
Last Name:WASHINGTON
Suffix:II
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 1:1417 LAWRENCE CRES
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1716
Mailing Address - Country:US
Mailing Address - Phone:773-544-8221
Mailing Address - Fax:
Practice Address - Street 1:1417 LAWRENCE CRES
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1716
Practice Address - Country:US
Practice Address - Phone:773-544-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNAMedicaid