Provider Demographics
NPI:1326265810
Name:GREGERSON, MARY BANKS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:BANKS
Last Name:GREGERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S ESPLANADE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-3522
Mailing Address - Country:US
Mailing Address - Phone:913-250-6512
Mailing Address - Fax:913-250-6512
Practice Address - Street 1:1116 S ESPLANADE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-3522
Practice Address - Country:US
Practice Address - Phone:913-250-6512
Practice Address - Fax:913-250-6512
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002585103T00000X
MO2011019793103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist