Provider Demographics
NPI:1023098134
Name:KURT H. GREGORY D.B.A. FAMILY SUPPORT SERVICES OF NORTHEN INDIANA
Entity type:Organization
Organization Name:KURT H. GREGORY D.B.A. FAMILY SUPPORT SERVICES OF NORTHEN INDIANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:260-244-0057
Mailing Address - Street 1:7311B W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6237
Mailing Address - Country:US
Mailing Address - Phone:260-432-2311
Mailing Address - Fax:260-432-2311
Practice Address - Street 1:7311B W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6237
Practice Address - Country:US
Practice Address - Phone:260-432-2311
Practice Address - Fax:260-432-2311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001414A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty