Provider Demographics
NPI:1306108873
Name:SHAHUM, GREGORY MICHAEL (PHD, MHA, OTR/L)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:SHAHUM
Suffix:
Gender:M
Credentials:PHD, MHA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11022 DAVID STONE DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-7415
Mailing Address - Country:US
Mailing Address - Phone:570-677-0274
Mailing Address - Fax:
Practice Address - Street 1:100 GOSSMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-2281
Practice Address - Country:US
Practice Address - Phone:910-246-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8304225X00000X
CT003443225X00000X
CT001929376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No376G00000XNursing Service Related ProvidersNursing Home Administrator