Provider Demographics
NPI:1710694385
Name:GREGORY, NEDDEIDTH E
Entity Type:Individual
Prefix:
First Name:NEDDEIDTH
Middle Name:E
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 FANEUIL HALL MARKET PL FL 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-6114
Mailing Address - Country:US
Mailing Address - Phone:617-863-9090
Mailing Address - Fax:
Practice Address - Street 1:196 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3677
Practice Address - Country:US
Practice Address - Phone:857-318-5047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7330458Medicaid