Provider Demographics
NPI:1962699561
Name:PRIESTAP, GRETA R (PHD)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:R
Last Name:PRIESTAP
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 W 12 MILE RD
Mailing Address - Street 2:120
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2182
Mailing Address - Country:US
Mailing Address - Phone:248-691-4774
Mailing Address - Fax:248-691-8129
Practice Address - Street 1:1695 W 12 MILE RD
Practice Address - Street 2:120
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2182
Practice Address - Country:US
Practice Address - Phone:248-691-4774
Practice Address - Fax:248-691-8129
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012676103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent