Provider Demographics
NPI:1497351340
Name:PALMER, GREGORY ALFRED (CAC-AD/S, CAC II)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALFRED
Last Name:PALMER
Suffix:
Gender:M
Credentials:CAC-AD/S, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 INDUSTRIAL PARK DR STE 104D
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2751
Mailing Address - Country:US
Mailing Address - Phone:310-818-0030
Mailing Address - Fax:
Practice Address - Street 1:21 INDUSTRIAL PARK DR STE 104D
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2751
Practice Address - Country:US
Practice Address - Phone:310-818-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC-1111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)