Provider Demographics
NPI:1467725721
Name:LAUDERDALE, GREGORY THOMAS
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:LAUDERDALE
Suffix:
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 1:12322 CLEARGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90604-3872
Mailing Address - Country:US
Mailing Address - Phone:562-242-1077
Mailing Address - Fax:562-947-4053
Practice Address - Street 1:12322 CLEARGLEN AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604
Practice Address - Country:US
Practice Address - Phone:562-242-1077
Practice Address - Fax:562-947-4053
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility