Provider Demographics
NPI:1407912363
Name:GREGG, JANOLYN S (PHD)
Entity Type:Individual
Prefix:
First Name:JANOLYN
Middle Name:S
Last Name:GREGG
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 1:2625 WESTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3614
Mailing Address - Country:US
Mailing Address - Phone:954-385-0353
Mailing Address - Fax:954-385-0353
Practice Address - Street 1:2625 WESTON RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3614
Practice Address - Country:US
Practice Address - Phone:954-385-0353
Practice Address - Fax:954-385-0353
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4483103T00000X, 103TB0200X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59332OtherBCBSFL
FL1407064462OtherFIRST COAST SERVICE OPTIONS, INC.