Provider Demographics
NPI:1598841314
Name:MILBOURNE, GREGORY BROUGHTON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BROUGHTON
Last Name:MILBOURNE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 W THIRD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2803
Mailing Address - Country:US
Mailing Address - Phone:610-348-7780
Mailing Address - Fax:610-690-5715
Practice Address - Street 1:13 W THIRD ST FL 3
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2803
Practice Address - Country:US
Practice Address - Phone:610-744-2960
Practice Address - Fax:610-744-2420
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical