1073672275 NPI number — GREGORY JOHN WIGHTMAN L.P.C.C. SUPV.

NPI Number: 1073672275
Health Care Provider/Practitioner: GREGORY JOHN WIGHTMAN L.P.C.C. SUPV.

NPI Number : 1073672275 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1073672275",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WIGHTMAN",
    "FirstName": "GREGORY",
    "MiddleName": "JOHN",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "L.P.C.C. SUPV.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "30 E BROAD ST",
    "SecondLineMailingAddress": "11TH FLOOR",
    "MailingAddressCityName": "COLUMBUS",
    "MailingAddressStateName": "OH",
    "MailingAddressPostalCode": "43215-3414",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "614-466-6583",
    "MailingAddressFaxNumber": "614-995-3268",
    "FirstLinePracticeLocationAddress": "2611 WAYNE AVE",
    "SecondLinePracticeLocationAddress": "BUILDING #66",
    "PracticeLocationAddressCityName": "DAYTON",
    "PracticeLocationAddressStateName": "OH",
    "PracticeLocationAddressPostalCode": "45420-1833",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "937-258-0440",
    "PracticeLocationAddressFaxNumber": "937-258-6235",
    "EnumerationDate": "12/06/2006",
    "LastUpdateDate": "07/08/2007",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "101Y00000X",
        "TaxonomyName": "Counselor",
        "LicenseNumber": "E0000394 SUPV",
        "LicenseNumberStateCode": "OH",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}