Healthcare Provider Details

I. General information

NPI: 1740879782
Provider Name (Legal Business Name): GREGORY D SHEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14511 JESSICA FALLS CIR
HOUSTON TX
77044-4969
US

IV. Provider business mailing address

14511 JESSICA FALLS CIR
HOUSTON TX
77044-4969
US

V. Phone/Fax

Practice location:
  • Phone: 281-900-4147
  • Fax:
Mailing address:
  • Phone: 281-900-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: