Provider Demographics
NPI:1063175792
Name:GREGG, GARRETT A (LSW)
Entity type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:A
Last Name:GREGG
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 S CRESTLINE BLOOMINGGROVE RD
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-9551
Mailing Address - Country:US
Mailing Address - Phone:567-215-6787
Mailing Address - Fax:
Practice Address - Street 1:1065 MEDINA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5375
Practice Address - Country:US
Practice Address - Phone:614-844-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2004971104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid