Provider Demographics
NPI:1982047270
Name:ROMANOFF, GREGORY C (MSED LADC CCS)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:C
Last Name:ROMANOFF
Suffix:
Gender:M
Credentials:MSED LADC CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1704
Mailing Address - Country:US
Mailing Address - Phone:207-774-7111
Mailing Address - Fax:207-775-1985
Practice Address - Street 1:400 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1704
Practice Address - Country:US
Practice Address - Phone:207-774-7111
Practice Address - Fax:207-775-1985
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECCS2832101YA0400X
MELC2417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)