Provider Demographics
NPI:1679091268
Name:GREGORY, SUSAN DAVIS (LCAS A)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DAVIS
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LCAS A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 QUAIL CREEK CT APT 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5084
Mailing Address - Country:US
Mailing Address - Phone:919-210-7728
Mailing Address - Fax:
Practice Address - Street 1:309 W MILLBROOK RD STE 161
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4261
Practice Address - Country:US
Practice Address - Phone:919-559-8690
Practice Address - Fax:919-882-1277
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21441101YA0400X
NC22950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)