Provider Demographics
NPI:1225289622
Name:RICH, GREGORY WAYNE (MDIV)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
Last Name:RICH
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 ELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1115
Mailing Address - Country:US
Mailing Address - Phone:541-944-7499
Mailing Address - Fax:
Practice Address - Street 1:815 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6713
Practice Address - Country:US
Practice Address - Phone:541-245-2787
Practice Address - Fax:541-899-3243
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0677106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor