Provider Demographics
NPI:1629470588
Name:OUTLAW, GREGORY (QMHP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:OUTLAW
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63357 CROOKED CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9304
Mailing Address - Country:US
Mailing Address - Phone:574-520-9044
Mailing Address - Fax:269-445-3836
Practice Address - Street 1:960 M 60 E
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9339
Practice Address - Country:US
Practice Address - Phone:269-445-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor