Provider Demographics
NPI:1376867556
Name:GREGORY, NIKE KONSTANTINA (LICSW)
Entity Type:Individual
Prefix:MISS
First Name:NIKE
Middle Name:KONSTANTINA
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4536
Mailing Address - Country:US
Mailing Address - Phone:978-476-3708
Mailing Address - Fax:
Practice Address - Street 1:42 THOMAS ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4536
Practice Address - Country:US
Practice Address - Phone:978-476-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1233301041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical