=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770913949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY ERN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2013
-----------------------------------------------------
Last Update Date | 12/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1940 58TH AVE STE D
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32966-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-444-6455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1940 58TH AVE STE D
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32966-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-444-6455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | SS673
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------