Basic Information
| Provider Information | |||||||||
| NPI: | 1134517220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGG | ||||||||
| FirstName: | CALLIE | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 40 TULLY RD. | ||||||||
| Address2: | 304 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082713960 | ||||||||
| FaxNumber: | 4082713909 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 TULLY RD. | ||||||||
| Address2: | 304 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082713960 | ||||||||
| FaxNumber: | 4082713909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2014 | ||||||||
| LastUpdateDate: | 12/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RI-G1307201216 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | RI-G1307201216 | 01 | CA | RASI | OTHER |