Provider Demographics
NPI:1790150456
Name:GREGG, DAVID (PHD, LP, CAADC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GREGG
Suffix:
Gender:M
Credentials:PHD, LP, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6418 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4017 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3731
Practice Address - Country:US
Practice Address - Phone:248-808-3875
Practice Address - Fax:269-350-5779
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016924103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist