Healthcare Provider Details

I. General information

NPI: 1760717524
Provider Name (Legal Business Name): AMANDA ANN GREGORY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W ADAMS ST
CHICAGO IL
60606-5101
US

IV. Provider business mailing address

300 W ADAMS ST STE 514
CHICAGO IL
60606-5108
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2221
  • Fax: 573-745-1196
Mailing address:
  • Phone: 573-365-2221
  • Fax: 573-745-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2008036881
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: