Basic Information
| Provider Information | |||||||||
| NPI: | 1962409649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETTER | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562363 | ||||||||
| FaxNumber: | 4014566744 | ||||||||
| Practice Location | |||||||||
| Address1: | 2756 POST RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028863003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4016916000 | ||||||||
| FaxNumber: | 4017387718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 01/14/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | MD08688 | RI | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 2084P0800X | MD08688 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7004198 | 05 | RI | MEDICAID |