MEDICARE: DR. MARYANN L GREGORY PHD

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	103T00000X	Psychologist		IL

General Provider Information

NPI Number	:	1851311013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYANN L GREGORY PHD

Provider Business Mailing Address
First Line	:	1429 N DEARBORN ST
Second Line	:	4N
City	:	CHICAGO
State	:	IL
Zip	:	60610-1558
Country	:	US
Telephone Number	:	312-203-9877
Fax Number	:	312-782-7001

Provider Business Practice Location Address
First Line	:	11 S LA SALLE ST
Second Line	:	#2600
City	:	CHICAGO
State	:	IL
Zip	:	60603-1203
Country	:	US
Telephone Number	:	312-203-9877
Fax Number	:	312-283-7001

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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