Provider Demographics
NPI:1750500294
Name:BREWER, GREGORY SCOTT (MFT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:BREWER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2649
Mailing Address - Country:US
Mailing Address - Phone:209-223-6412
Mailing Address - Fax:209-223-0920
Practice Address - Street 1:1001 BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2649
Practice Address - Country:US
Practice Address - Phone:209-223-6412
Practice Address - Fax:209-223-0920
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22775106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC22775OtherMARRIAGE AND FAMILY THERA