Basic Information
| Provider Information | |||||||||
| NPI: | 1891367835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 ATLANTIC AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145879007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1025 ATLANTIC AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145879007 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | F1216499 | 01 | CA | CALIFORNIA DRIVERS LICENSE | OTHER |