Provider Demographics
NPI:1144670423
Name:AMMONS, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:AMMONS
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 1:124 E MIRACLE STRIP PKWY
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1988
Mailing Address - Country:US
Mailing Address - Phone:850-729-2242
Mailing Address - Fax:
Practice Address - Street 1:419 RACETRACK RD NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4612
Practice Address - Country:US
Practice Address - Phone:850-862-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLQASP-S-14981103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst