Provider Demographics
NPI:1356702880
Name:GREGORY, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GREGORY
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 1:7375 WOODWARD AVE STE 2800
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3157
Mailing Address - Country:US
Mailing Address - Phone:313-710-8744
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:7375 WOODWARD AVE STE 2800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3157
Practice Address - Country:US
Practice Address - Phone:313-710-8744
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7402000063103K00000X, 106E00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other