Provider Demographics
NPI:1821455049
Name:GREGORY, KATHY ROSE
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ROSE
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:PO BOX 390753
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-0013
Mailing Address - Country:US
Mailing Address - Phone:310-508-1178
Mailing Address - Fax:
Practice Address - Street 1:2759 MOUNTBERY DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-8028
Practice Address - Country:US
Practice Address - Phone:310-508-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor