Provider Demographics
NPI:1457936874
Name:CLEVENGER, GREGORY L
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11623 SHELL BARK LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-1382
Mailing Address - Country:US
Mailing Address - Phone:810-603-0857
Mailing Address - Fax:
Practice Address - Street 1:1100 W SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-2033
Practice Address - Country:US
Practice Address - Phone:517-887-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor