Provider Demographics
NPI:1982839767
Name:WORTHINGTON, GREGORY JOHN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:WORTHINGTON
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 1:401 W FRONT ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2259
Mailing Address - Country:US
Mailing Address - Phone:231-932-0232
Mailing Address - Fax:231-932-0232
Practice Address - Street 1:401 W FRONT ST
Practice Address - Street 2:SUITE #3
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2259
Practice Address - Country:US
Practice Address - Phone:231-932-0232
Practice Address - Fax:231-932-0232
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB81123OtherBLUE CROSS BLUE SHIELD PIN