MEDICARE: GREGORY JOHN WIGHTMAN L.P.C.C. SUPV.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	E0000394 SUPV	OH

General Provider Information

NPI Number	:	1073672275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY JOHN WIGHTMAN L.P.C.C. SUPV.

Provider Business Mailing Address
First Line	:	30 E BROAD ST
Second Line	:	11TH FLOOR
City	:	COLUMBUS
State	:	OH
Zip	:	43215-3414
Country	:	US
Telephone Number	:	614-466-6583
Fax Number	:	614-995-3268

Provider Business Practice Location Address
First Line	:	2611 WAYNE AVE
Second Line	:	BUILDING #66
City	:	DAYTON
State	:	OH
Zip	:	45420-1833
Country	:	US
Telephone Number	:	937-258-0440
Fax Number	:	937-258-6235

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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