Provider Demographics
NPI:1982867933
Name:GREGORY, ERIC WILLIAM (MA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2303
Mailing Address - Country:US
Mailing Address - Phone:314-206-3726
Mailing Address - Fax:
Practice Address - Street 1:3637 UTAH PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4828
Practice Address - Country:US
Practice Address - Phone:314-330-9748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MO2009014951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2009014951OtherMO DIVISION OF PROFESSIONAL REGISTRATION