Basic Information
| Provider Information | |||||||||
| NPI: | 1790228211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSTLER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 LEROY GEORGE DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287217430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284528651 | ||||||||
| FaxNumber: | 8284528393 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 LEROY GEORGE DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287217430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284528651 | ||||||||
| FaxNumber: | 8284528393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2016 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P010522 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | P010522 | 01 | NC | LICENSE - NC | OTHER |