Provider Demographics
NPI:1568498160
Name:MAVROMATIS, GREGORY PETER (MSW)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:PETER
Last Name:MAVROMATIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-6345
Mailing Address - Country:US
Mailing Address - Phone:847-360-1003
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-3332
Practice Address - Fax:224-610-3789
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0081841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-008184Medicare UPIN