Provider Demographics
NPI:1679717797
Name:MICHAEL, GREGORY ALAN (DED)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27907-0189
Mailing Address - Country:US
Mailing Address - Phone:252-338-4044
Mailing Address - Fax:252-337-7928
Practice Address - Street 1:1417 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6533
Practice Address - Country:US
Practice Address - Phone:252-338-4044
Practice Address - Fax:252-337-7928
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC864103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool