Provider Demographics
NPI:1780809335
Name:GREGORI, TARA MARIE (MSP, CCC-SLP, BCBA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:GREGORI
Suffix:
Gender:F
Credentials:MSP, CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 GOVERNORS CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9257
Mailing Address - Country:US
Mailing Address - Phone:843-813-1538
Mailing Address - Fax:843-888-8133
Practice Address - Street 1:966 GOVERNORS CT
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-9257
Practice Address - Country:US
Practice Address - Phone:843-813-1538
Practice Address - Fax:843-884-6190
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2212235Z00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0412Medicaid
SCEXG324Medicaid