Provider Demographics
NPI:1801117049
Name:MOTLEY, GREGORY (LMSW, LADC, MAC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MOTLEY
Suffix:
Gender:M
Credentials:LMSW, LADC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 POPLAR AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-7278
Mailing Address - Country:US
Mailing Address - Phone:901-728-5554
Mailing Address - Fax:901-728-6011
Practice Address - Street 1:1203 POPLAR AVE
Practice Address - Street 2:SUITE #5
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7278
Practice Address - Country:US
Practice Address - Phone:901-728-5554
Practice Address - Fax:901-728-6011
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK308101YA0400X
TNC83434101YA0400X
TN5873101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3728928Medicaid