Provider Demographics
NPI:1972545671
Name:CRISENBERY, GREGORY SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SCOTT
Last Name:CRISENBERY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 ASBURY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3204
Mailing Address - Country:US
Mailing Address - Phone:847-869-3148
Mailing Address - Fax:847-686-4000
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:847-686-4000
Practice Address - Fax:847-686-4000
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005718103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical