Provider Demographics
NPI:1891183810
Name:EATMON, GREGORY DARRYL SR
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DARRYL
Last Name:EATMON
Suffix:SR
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 1:42 W WASHINGTON LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2602
Mailing Address - Country:US
Mailing Address - Phone:267-297-7439
Mailing Address - Fax:
Practice Address - Street 1:42 W WASHINGTON LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2602
Practice Address - Country:US
Practice Address - Phone:267-297-7439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000314103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst