Basic Information
| Provider Information | |||||||||
| NPI: | 1396035986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENMAN | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | GARDNER | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13660 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481951320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342857098 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2011 | ||||||||
| LastUpdateDate: | 05/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | L2079431 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YS0200X | PV0000000772837 | MI | N | Behavioral Health & Social Service Providers | Counselor | School |
No ID Information.