Provider Demographics
NPI:1053740357
Name:WORTLEY, GREGORY
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:WORTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2329
Mailing Address - Country:US
Mailing Address - Phone:517-548-0081
Mailing Address - Fax:517-548-0498
Practice Address - Street 1:2280 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8503
Practice Address - Country:US
Practice Address - Phone:517-546-4126
Practice Address - Fax:517-546-1300
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010832521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical