Provider Demographics
NPI:1386711760
Name:STRONG, GREG
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:STRONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEWELL
Other - Middle Name:
Other - Last Name:STRONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1615 W LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3828
Mailing Address - Country:US
Mailing Address - Phone:602-330-2073
Mailing Address - Fax:
Practice Address - Street 1:1615 W LA SALLE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-3828
Practice Address - Country:US
Practice Address - Phone:602-330-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10728385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096784OtherAHCCCS ID