Provider Demographics
NPI:1013474576
Name:GREGORY, KARNISHA MARDELL
Entity Type:Individual
Prefix:
First Name:KARNISHA
Middle Name:MARDELL
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22703 W WATERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-7669
Mailing Address - Country:US
Mailing Address - Phone:281-762-2394
Mailing Address - Fax:
Practice Address - Street 1:22703 W WATERLAKE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-7669
Practice Address - Country:US
Practice Address - Phone:832-453-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35999235Z00000X, 364SP0811X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No364SP0811XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Chronically Ill