Provider Demographics
NPI:1316614548
Name:GREGG, MICHAEL JAMES (LSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
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 1:106 S LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1663
Mailing Address - Country:US
Mailing Address - Phone:630-801-1669
Mailing Address - Fax:
Practice Address - Street 1:1813 N MILL ST STE B
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4872
Practice Address - Country:US
Practice Address - Phone:630-428-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1105711041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical