Provider Demographics
NPI:1326045063
Name:CORRELL, GREGORY (PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CORRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17330 W CENTER RD
Mailing Address - Street 2:SUITE 110-282
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2392
Mailing Address - Country:US
Mailing Address - Phone:317-446-9288
Mailing Address - Fax:
Practice Address - Street 1:9904 RIDGEWAY CT
Practice Address - Street 2:
Practice Address - City:MC CORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-9790
Practice Address - Country:US
Practice Address - Phone:317-335-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040294A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200018970AMedicaid
INR77491Medicare UPIN
IN521150BMedicare ID - Type Unspecified