Healthcare Provider Details

I. General information

NPI: 1104371053
Provider Name (Legal Business Name): KRISTEN SHAE GREGORY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 KENNILWORTH RD SW
DECATUR AL
35603-1316
US

IV. Provider business mailing address

303D BELTLINE PL SW # 432
DECATUR AL
35603-1713
US

V. Phone/Fax

Practice location:
  • Phone: 256-627-5188
  • Fax: 866-268-4763
Mailing address:
  • Phone: 256-627-5188
  • Fax: 866-268-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC11890
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4589C
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4589C
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904020394
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: