Provider Demographics
NPI:1851529648
Name:MAYNE, GREGGORY TYLER
Entity Type:Individual
Prefix:
First Name:GREGGORY
Middle Name:TYLER
Last Name:MAYNE
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 1:624 GARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-4638
Mailing Address - Country:US
Mailing Address - Phone:707-565-7817
Mailing Address - Fax:
Practice Address - Street 1:2227 CAPRICORN WAY STE 207
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5486
Practice Address - Country:US
Practice Address - Phone:707-565-7817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115984106H00000X
CA86192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist