Provider Demographics
NPI:1356634885
Name:GREGORY, VIRGIL LEE JR (MSW LSW)
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:LEE
Last Name:GREGORY
Suffix:JR
Gender:M
Credentials:MSW LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 NORTH SHADELAND AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1734
Practice Address - Country:US
Practice Address - Phone:317-355-1800
Practice Address - Fax:317-355-1803
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001166A101YA0400X
IN33004885A104100000X
IN34006474A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530Medicaid
IN165490114Medicare PIN
IN150074Medicare PIN