Provider Demographics
NPI:1518463769
Name:GREGG, RAEQUEL
Entity Type:Individual
Prefix:
First Name:RAEQUEL
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HILLSDALE AVE APT 124
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-1143
Mailing Address - Country:US
Mailing Address - Phone:408-507-0813
Mailing Address - Fax:
Practice Address - Street 1:800 HILLSDALE AVE APT 124
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95136-1143
Practice Address - Country:US
Practice Address - Phone:408-507-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty