Provider Demographics
NPI:1740535459
Name:GRIFFIN, GREG (MA, REV)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:MA, REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3827 ROSWELL RD
Mailing Address - Street 2:SUITE 100-C
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6262
Mailing Address - Country:US
Mailing Address - Phone:770-310-7190
Mailing Address - Fax:
Practice Address - Street 1:3827 ROSWELL RD
Practice Address - Street 2:SUITE 100-C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6262
Practice Address - Country:US
Practice Address - Phone:770-310-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAP05093169101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral