Provider Demographics
NPI:1952377749
Name:GRIDLEY BEHAVIORAL HEALTHCARE, P.A.
Entity Type:Organization
Organization Name:GRIDLEY BEHAVIORAL HEALTHCARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-522-3976
Mailing Address - Street 1:2100B N. HERRITAGE STREET
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-2222
Mailing Address - Country:US
Mailing Address - Phone:252-522-3976
Mailing Address - Fax:252-522-1582
Practice Address - Street 1:2100B N HERRITAGE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-2222
Practice Address - Country:US
Practice Address - Phone:252-522-3976
Practice Address - Fax:252-522-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000369Medicaid
NC1688Medicare PIN