Provider Demographics
NPI:1518220375
Name:GREGORY, RANDI M (SPECIAL ED TEACHER)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:M
Last Name:GREGORY
Suffix:
Gender:F
Credentials:SPECIAL ED TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 E GRANADA AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6528
Mailing Address - Country:US
Mailing Address - Phone:631-680-9007
Mailing Address - Fax:
Practice Address - Street 1:1 SCOUTING BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-297-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY384621101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist