Provider Demographics
NPI:1457396293
Name:CRUCIAN, GREGORY P (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
Last Name:CRUCIAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:PAUL
Other - Last Name:CRUCIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5313 STONE CREST DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-8757
Mailing Address - Country:US
Mailing Address - Phone:915-255-9869
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:FORT RILEY
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442
Practice Address - Country:US
Practice Address - Phone:850-883-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5730103T00000X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371230300Medicaid
FL68919Medicare ID - Type Unspecified