Provider Demographics
NPI:1669829057
Name:MCBRIDE, GREGORY JAN
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAN
Last Name:MCBRIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 AUTUMN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8313
Mailing Address - Country:US
Mailing Address - Phone:586-764-0812
Mailing Address - Fax:
Practice Address - Street 1:1455 S LAPEER RD
Practice Address - Street 2:175 NORTH
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1467
Practice Address - Country:US
Practice Address - Phone:248-393-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002079101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional