Provider Demographics
NPI:1780187211
Name:STOCKDALE, GREGORY M
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:STOCKDALE
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 1:62 E STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5969
Mailing Address - Country:US
Mailing Address - Phone:740-366-7303
Mailing Address - Fax:
Practice Address - Street 1:62 E STEVENS ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5969
Practice Address - Country:US
Practice Address - Phone:740-366-7303
Practice Address - Fax:740-366-7305
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)