Provider Demographics
NPI:1215916804
Name:WILLIAMS, GREGORY JAY
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:JAY
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 80894
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37414-7894
Mailing Address - Country:US
Mailing Address - Phone:423-236-5888
Mailing Address - Fax:423-476-4808
Practice Address - Street 1:11014 APISON PIKE
Practice Address - Street 2:
Practice Address - City:APISON
Practice Address - State:TN
Practice Address - Zip Code:37302-0000
Practice Address - Country:US
Practice Address - Phone:423-899-2204
Practice Address - Fax:423-698-4045
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3017014Medicare UPIN
TN3686825Medicare ID - Type UnspecifiedIDENTIFICATION NUMBER