Basic Information
Provider Information | |||||||||
NPI: | 1619079910 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHUGAR | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 201 GOVERNMENT AVE SW | ||||||||
Address2: | SUITE 305 | ||||||||
City: | HICKORY | ||||||||
State: | NC | ||||||||
PostalCode: | 286022954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282671740 | ||||||||
FaxNumber: | 8282671746 | ||||||||
Practice Location | |||||||||
Address1: | 201 GOVERNMENT AVE SW | ||||||||
Address2: | SUITE 305 | ||||||||
City: | HICKORY | ||||||||
State: | NC | ||||||||
PostalCode: | 286022954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282671740 | ||||||||
FaxNumber: | 8282671746 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2006 | ||||||||
LastUpdateDate: | 10/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1198 | NC | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 6107140 | 05 | NC |   | MEDICAID |