Provider Demographics
NPI:1184449167
Name:WIATROWSKI, GREGORY (MA CAS NCSP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WIATROWSKI
Suffix:
Gender:M
Credentials:MA CAS NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N PAYSON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-1121
Mailing Address - Country:US
Mailing Address - Phone:410-396-0776
Mailing Address - Fax:
Practice Address - Street 1:1600 N PAYSON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1121
Practice Address - Country:US
Practice Address - Phone:410-396-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCER-65929B1S7P9103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool