Healthcare Provider Details

I. General information

NPI: 1164339057
Provider Name (Legal Business Name): DREAM MYSTIQUE GREGORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N WESTERN AVE
MARION IN
46952-3403
US

IV. Provider business mailing address

1519 W 3RD ST
MARION IN
46952-3551
US

V. Phone/Fax

Practice location:
  • Phone: 765-382-8222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: