Provider Demographics
NPI:1104959378
Name:GREGORY, ROBERT DARRYL (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DARRYL
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 TRINIDAD BND
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3233
Mailing Address - Country:US
Mailing Address - Phone:619-435-6628
Mailing Address - Fax:619-435-6628
Practice Address - Street 1:138 B AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1511
Practice Address - Country:US
Practice Address - Phone:609-435-6628
Practice Address - Fax:619-435-6628
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10106103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10106Medicare ID - Type Unspecified