Healthcare Provider Details

I. General information

NPI: 1376867556
Provider Name (Legal Business Name): NIKE KONSTANTINA GREGORY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 THOMAS ST
MEDFORD MA
02155-4536
US

IV. Provider business mailing address

42 THOMAS ST
MEDFORD MA
02155-4536
US

V. Phone/Fax

Practice location:
  • Phone: 978-476-3708
  • Fax:
Mailing address:
  • Phone: 978-476-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number123330
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: