Provider Demographics
NPI:1821140245
Name:GREGG, ALFRED LEROY JR (MFT)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:LEROY
Last Name:GREGG
Suffix:JR
Gender:M
Credentials:MFT
Other - Prefix:MR
Other - First Name:ALFRED
Other - Middle Name:
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:21030 MISSION ST
Mailing Address - Street 2:STE. A
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-6769
Mailing Address - Country:US
Mailing Address - Phone:661-822-8979
Mailing Address - Fax:661-822-5729
Practice Address - Street 1:21030 MISSION ST
Practice Address - Street 2:STE. A
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6769
Practice Address - Country:US
Practice Address - Phone:661-822-8979
Practice Address - Fax:661-822-5729
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC21080106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821140425Medicaid