Provider Demographics
NPI:1376012740
Name:SMITH, GREGORY ROY SR
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROY
Last Name:SMITH
Suffix:SR
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 1:19 HONOR DR
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:AL
Mailing Address - Zip Code:36856-2815
Mailing Address - Country:US
Mailing Address - Phone:762-261-1090
Mailing Address - Fax:
Practice Address - Street 1:19 HONOR DR
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:AL
Practice Address - Zip Code:36856-2815
Practice Address - Country:US
Practice Address - Phone:762-261-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04348101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty