Provider Demographics
NPI:1396161873
Name:SMITH, GREG
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 INDEPENDENCE BLVD STE 326
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-2978
Mailing Address - Country:US
Mailing Address - Phone:757-490-0377
Mailing Address - Fax:757-497-1327
Practice Address - Street 1:281 INDEPENDENCE BLVD STE 326
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2978
Practice Address - Country:US
Practice Address - Phone:757-490-0377
Practice Address - Fax:757-497-1327
Is Sole Proprietor?:No
Enumeration Date:2014-03-08
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002984101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional